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OBJECTIVE: To compare the effectiveness of a cervical pessary and vaginal progesterone to prevent spontaneous preterm births in pregnant women with cervical lengths 25 mm or less as measured by transvaginal ultrasonography. METHODS: This was a multicenter, open-label, randomized, noninferiority trial. Women with singleton pregnancies and a short cervix (25 mm or less) measured transvaginally at the second-trimester ultrasonogram were invited to participate. They were computer-randomized (one to one) into cervical pessary placement or treatment with vaginal progesterone (200 mg/24 hours). The primary outcome was spontaneous preterm delivery before 34 weeks of gestation. The noninferiority margin was set at 4% with a 0.025 one-sided α level and a statistical power of 80%. That is, if the 95% CI upper bound exceeded 4%, the pessary could not be deemed noninferior. A sample size of 254 women was required to show noninferiority of the pessary to progesterone. RESULTS: The trial was conducted from August 2012 to April 2016 with the participation of 27 Spanish hospitals. A total of 254 patients were enrolled and 246 included in the intention-to-treat analysis. Demographic and baseline characteristics were similar across groups. The rate of spontaneous delivery before 34 weeks of gestation was 14% (n=18/127) in the pessary group and 14% (n=17/119) in the progesterone group with a risk difference of -0.11% (95% CI -8.85% to 8.62%; P=.99), that is, noninferiority was not shown for the pessary. The incidence of increased vaginal discharge (87% vs 71%, P=.002) and discomfort (27% vs 3%, P<.001) was significantly higher in the pessary group. CONCLUSION: A cervical pessary was not noninferior to vaginal progesterone for preventing spontaneous birth before 34 weeks of gestation in pregnant women with short cervixes. CLINICAL TRIAL REGISTRATION: EU Clinical Trials Register, 2012-000241-13; ClinicalTrials.gov, NCT01643980.

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Introducción: La inversión uterina es una emergencia obstétrica y una rara complicación del tercer estadio del trabajo del parto. Objetivo: Describir las características clínicas, diagnósticas, terapéuticas y evolutivas de las pacientes con inversiones uterinas. Material y métodos: Estudio retrospectivo basado en 6 parturientas diagnosticadas de inversión uterina en el posparto en el Hospital de León durante el año 2005. Resultados: Las inversiones se produjeron en primíparas a término, con analgesia epidural y con partos instrumentales. En el 83% se utilizó oxitocina durante la dilatación, cuya duración media fue de 6,5 h. El diagnóstico fue mayoritariamente clínico, excepto en un caso grado II, que precisó una ecografía y cuya resolución fue quirúrgica. En el resto de los casos la resolución fue mediante reposición manual (83%). La disminución media de la hemoglobina preparto tras el episodio fue de 2,7 g/dl y sólo 2 pacientes precisaron transfusión. Conclusiones: Los factores predisponentes son la hipotonía uterina, la implantación fúndica y las placentas accretas. El 60% se debe a maniobras precipitadas, como la tracción de cordón o una presión fúndica inapropiada. El diagnóstico es esencialmente clínico. Aunque poco común, si no es diagnosticada, la inversión uterina pueda causar una hemorragia importante y shock, y provocar la muerte materna. Una vez diagnosticada, se deben tomar medidas para estabilizar a la paciente, realizándose inmediatamente la reducción manual. Los tocolíticos, como la ritrodina, la terbutalina y el sulfato de magnesio, o los anestésicos halogenados, pueden administrarse para facilitar la reversión. La nitroglicerina por vía intravenosa puede ser una alternativa. El fracaso requeriría tratamiento quirúrgico

Introduction: Uterine inversion is a rare obstetric emergency that occurs during the third stage of labor. Objective: To describe the clinical, diagnostic and therapeutic characteristics and outcomes in patients with uterine inversion. Material and methods: We performed a retrospective study of six patients with uterine inversion during the puerperium in the Hospital de Leon (Spain) in 2005. Results: All inversions occurred in primiparous women with epidural anesthesia and instrumental delivery at term. Oxytocin was used in 83% during dilatation, the average duration of which was 6.5 hours. Diagnosis was mainly clinical except in one grade II inversion, which required ultrasonography and was resolved surgically. The remaining cases were resolved through manual reduction (83%). After the episode, hemoglobin levels were reduced by an average of 2.7 g/dl from prepartum levels, and only two patients required blood transfusion. Conclusions: Factors predisposing to uterine inversion were hypotonic uterus, fundal implantation of the placenta, and placenta accreta. Sixty percent of all cases were caused by precipitous maneuvers including traction on the cord or improper fundal pressure. Diagnosis is essentially clinical. Although uncommon, uterine inversion will result in severe hemorrhage and shock if left unrecognized, leading to maternal death. Once a diagnosis is made, immediate measures must be taken to stabilize the mother. Manual manipulation should be attempted immediately to reverse the inversion. Tocolytics, such as ritrodine, magnesium sulphate and terbutaline, or halogenated anesthetics may be administered to relax the uterus and aid its reversal. Intravenous nitroglycerin is an alternative to tocolytics. Failure of reversion or recurrence requires surgical treatment (AU)

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