JOURNAL READING AND

CRITICAL APPRAISAL
Oleh:
Nindriya Kurniandari, S. Ked

Perceptor:
dr. Wahdi Sdj, Sp.OG
Introduction
Prematurity remains the foremost cause of
neonatal mortality and morbidity
One of the challenges in the management of
women who present with preterm labor (PTL) is
the distinction between true and false PTL, since
fewer than 15% of those presenting with
threatened PTL will actually deliver within 7 days
of presentation or before 35 weeks gestation.
One of the most widely investigated tools for the
prediction of PTD in women with a singleton
pregnancy and threatened PTL is sonographic
measurement of cervical length (CL)
there is only limited information regarding the
performance of CL in women with twin
pregnancies who present with threatened PTL
(P) opulation /problem: Overall, 218 women with a twin
pregnancy
and 1077 women with a singleton pregnancy, who
presented with PTL

(I) ntervention : underwent sonographic measurement of

CL using transvaginal ultrasound

(C) omparison : was compared with that in a control

group of women with singleton pregnancies with
threatened PTL

(O) utcomes : cervical funneling or a change in CL

Validitas Subyek Penelitian
all women who presented with threatened
PTL in the presence of intact membranes
and underwent sonographic measurement
of CL in a tertiary referral medical center
betweenJanuary 2007 and December 2012.
The study group included women with twin
pregnancies who presented with
threatened PTL
Validitas Metode Penelitian
Metode: retrospective cohort study
Inclusion criteria: women who presented
at a gestational age of 24+0 to 33+6weeks
were included in either group.

Threatened PTL was defined as the

presence of at least three regular and
painful uterine contractions within a 30-min
period.
Measurement of CL was performed
transvaginally after the patients had emptied
their bladder and accordingto the standard
technique

Briefly, the measurement was performed in the

sagittal plane, visualizing the full length of the
endocervical canal, from the internal cervical os
to the external cervical os, while exerting as
little pressure as possible with the transducer.
At least three measurements were obtained and
the shortest measurement was recorded.
All sonographic examinations were
performed by physicians specialized in
ultrasonography or by experienced
sonographers, using the following
ultrasound systems: Voluson E8 and
Voluson 730 Expert (GE Medical Systems,
Kretz Ultrasound, Zipf, Austria) and ATL
5000 (Philips Healthcare, Best, The
Netherlands).
Exclusion Criteria
women with high-order multiple gestations (triplets and
above)
monoamniotic twins
Complicated monochorionic twins (twintwin transfusion
syndrome
or twin anemiapolycythemia sequence)
Cervical cerclage
cervical dilatation >3 cm at presentation
pregnancies complicated by placental abruption
Chorioamnionitis
stillbirth or major fetal anomalies,
women who underwent indicated preterm delivery
before 37+0 weeks gestation for any maternal or fetal
indication or who did not deliver in our medical center
Validitas Outcome
The accuracy of CL in predicting
spontaneous PTD before 37, 34 and 32
weeks gestation and within 14 and 7 days
of presentation in women with a twin
pregnancy was calculated and compared
with the predictive accuracy in singleton
pregnancies.
 Pertanyaan Validitas Telaah
Kritis
1. Apakah dilakukan randomisasi dan apakah daftar
randomisasi disegel? Ya
2. Apakah pemantauan subyek penelitian cukup lama dan
lengkap? Ya
3. Apakah seluruh subyek yang ikut dalam peneltian dihitung
dalam kesimpulan akhir sesuai dengan alokasi awalnya? Ya
4. Apakah peneliti dan subyek tidak mengetahui siapa yang
menerima perlakuan dan siapa yang menjadi kontrol
(ketersamaran)? Ya
5. Selain perlakuan yang sedang diuji, apakah kedua
kelompok (kelompok perlakuan dan kelompok pembanding)
mendapat perlakuan yang sama? Ya
6. Apakah kedua kelompok tersebut sebanding pada awal
percobaan? Yang dimaksud sebanding di sini ialah
sebanding dalam hal faktor-faktor prognostik yang
mempengaruhi hasil keluaran. Ya
Analisis Statistik
Students t-test and the Mann
Whitney U-test were used to compare
continuous variables, with and without
normal distribution, between the twin and
singleton groups, respectively, while the
chi-square and Fishers exact tests were
used for categorical variables.
Covariance (ANCOVA) test. identified
initially through visual inspection of the
graphs and were then confirmed by
comparison of the slopes of the regression
lines (describing the rate of PTD as a function
of CL) above and below these thresholds,
KaplanMeier survival analysis was used
to compare the proportion of pregnancies
undelivered according to time from
presentation between the twin and singleton
groups, stratified by CL at presentation
The log-rank test was used to compare the
survival distributions.
Spearmans correlation coefficient was
used to assess the correlation between CL at
presentation and examination-to-delivery
interval.
Multivariable logistic regression analysis
was used to assess the association between CL
as a continuous measure and the risk of PTD in
the twin and singleton groups, while controlling
for potential confounders.
ROC analysis was also used to calculate
standardized outcome-specific thresholds
Figure 4 KaplanMeier survival plot showing difference in examination-to-delivery interval
between twin ( ) and singleton ( )
pregnancies following presentation with threatened preterm labor according to cervical length at
examination of: (a) <10 mm;
(b) 1019 mm; (c) 2029 mm; and (d) 30 mm. P-values refer to comparison of survival curves using
Importancy
To assess the accurancy and determine the
optimal treshhold of sonographic CL for
prediction of PTD.
Applicability Jurnal
Setelah menyimpulkan bahwa suatu uji
klinis telah valid dan hasilnya cukup
penting, maka pertanyaan selanjutnya
adalah apakah hasil uji klinis ini dapat
diterapkan pada pasien yang kita hadapi di
fasilitas kesehatan tempat kita bekerja?
Ya, dapat diterapkan pada pasien di
Indonesia
Conclusion
In women with PTL, the performance of CL
as a test for the prediction of PTD is similar
in twin and singleton pregnancies.
However, the optimal threshold of CL for
the prediction of PTD appears to be higher
in twin pregnancies, mainly owing to the
higher baseline risk for PTD in these
pregnancies