Transvaginal cervical cerclage: evidence for perioperative management strategies

Cervical elastography using E-Cervix™ for prediction of preterm birth in twin pregnancies with threatened preterm labor

OBJECTIVE

To evaluate the prediction performance of E-Cervix™ for preterm birth in twin pregnancies with threatened preterm labor.

METHODS

This was a single-center retrospective cohort study of twin pregnancies presenting to obstetrics triage for threatened preterm labor (PTL) between 23 0/7 - 33 6/7 weeks who received screening for PTL with transvaginal ultrasound cervical length (TVU CL) and cervical elastography with E-Cervix™ at the time of triage. Cervical elastography parameters were examined and compared between women who delivered preterm and those who did not. The quantification of cervical strain was calculated by a data analysis system that directly analyzes raw data from the region of interest (ROI) and described as hardness ratio (HR), mean strain level within 1 cm from internal (IOS) and external (EOS) os.

RESULTS

63 twin gestations without prior preterm birth and with threatened PTL between 23 0/7 - 33 6/7 weeks of gestation were included in the study. 27 (42.9 %) had cervical length < 25 mm, and were admitted for true PLT. Out of the 36 women with cervical length ≥ 25 mm, 6 (16.7 %) were admitted. Women with threatened PTL had significantly higher HR compared to those with true PTL (p < 0.01), and significantly lower IOS and EOS. Women who delivered preterm had significantly higher HR compared to those who did not delivery preterm and significantly lower IOS and EOS, in overall cohort, and in the subset of women with true PTL. Incidences of HR < 50 % and < 35 % were statistically significantly higher in women who delivered preterm compared to those who did not (p < 0.01).

CONCLUSION

Cervical elastography with E-Cervix™ may be useful for assessment of twin gestations presenting to obstetrics triage for threatened PTL.

Short Cervix Following Initial Cerclage-Reinforcing Cerclage Versus Expectant Management

OBJECTIVES

To determine whether reinforcing cerclage following ultrasound evidence of cerclage failure before 24 weeks is an effective method to delay gestational age at delivery, and to decrease the rate of preterm and peri-viable delivery.

METHODS

A retrospective review was conducted for all patients who underwent any cervical cerclage procedure at a single tertiary care centre in Toronto, Canada between 1 December 2007 and 31 December 2017.

RESULTS

Of 1482 cerclage procedures completed during the study period, 40 pregnant persons who underwent reinforcing cerclage were compared with 40 pregnant persons who were found to have cerclage failure before 24 weeks but were managed expectantly. After adjusting for the shortest cervical length measured prior to 24 weeks, there was no significant difference between the reinforcing cerclage and control group for gestational age at delivery, preterm, or peri-viable birth (P = 0.52, P = 0.54, P = 0.74, respectively). In an unadjusted model, there was a statistically significant increase in placental infection identified on postpartum placenta pathology in the reinforcing cerclage group compared with the expectant management group, 92.9% compared with 66.7% (P = 0.028).

CONCLUSION

Reinforcing cerclage is unlikely to successfully delay the gestational age at delivery and reduce rates of preterm and pre-viable birth, especially if irreversible and progressive cervical change has begun. Future work should examine the role of preoperative amniocentesis to explore the impact of pre-existing intra-amniotic infection and reinforcing cerclage success.

A nomogram for predicting prognosis of patients with cervical cerclage

Introduction

Cervical insufficiency is an increased risk of midterm miscarriage and early preterm birth which increase the risk of fetal loss. This study aimed to construct a nomogram for patients with cervical insufficiency after cervical cerclage, which may assist clinicians to have individualized treatment for patients with cervical insufficiency.

Methods

A study was done retrospectively from January 2013 through July 2022 in our hospital. The primary outcomes were delivered at more than 28, 30, 32, or 34 gestational weeks. Kaplan-Meier curves were applied to analyze 17 variables. All patients were randomly split (147:64) into development and validation cohorts. Based on the multivariate Cox regression analysis, a nomogram was constructed through the 'rms' package in R.

Results

A total of 211 patients with cervical insufficiency were enrolled: 121 had history-indicated cerclage; 58 had ultrasound-indicated cerclage and 32 had emergency cerclage. Times of gestations, times of miscarriages, IVF, abdominal pain, diagnostic classification, preoperative and postoperative management were demonstrated to impact overall extended days when delivering at more than 28 gestational weeks was set as the primary outcome. Except for preoperative and postoperative management, the above other five variables impacted the primary outcomes of delivering at more than 30, 32, or 34 gestational weeks. Postoperative tocolytics had an impact on the prognosis of patients who delivered at more than 30 gestational weeks. In development cohort data, a nomogram was established to predict overall extended days of patients with cervical cerclage. In present study, C-index was 0.662 in the development cohort and 0.687 in the validation cohort respectively, suggesting that the model presented some satisfied prediction. Moreover, the clinical decision curves for patients with delivering at more than 28, 30, 32 or 34 weeks set as primary outcomes also displayed that this nomogram demonstrated good clinical predictive usefulness.

Conclusions

The nomogram developed in this study may be a valuable tool assisting clinicians to evaluate outcomes of patients with cervical insufficiency after cervical cerclage, which helps them develop individualized management for the patients.

Predictive value of serum inflammatory markers for histological chorioamnionitis among women with preterm premature rupture of membranes after undergoing cervical cerclage

PURPOSE

To determine the predictive value of maternal White Blood Cells (WBC), neutrophils, and C-Reactive Protein (CRP) for diagnosing Histological Chorioamnionitis (HCA) among women with Preterm Premature Rupture of Membranes (PPROM) who underwent cervical cerclage.

METHODS

A retrospective cross-sectional study was conducted among women with singleton pregnancy and PPROM, who underwent cervical cerclage during 2018-2020.

RESULTS

A total of 55 eligible women were included in the final analysis, including 36 (61.02%) cases with HCA and 19 (38.98%) without HCA. Women with HCA had higher WBC count (12.31 ± 2.80) × 109/L and neutrophil count (9.67 ± 2.90)×109/L than those without HCA (10.35 ± 2.53) × 109/L and 7.82 ± 2.82 × 109/L, respectively) (both p < 0.05). The cut-off value of WBC count at 10.15×109/L was found to be the most effective in identifying HCA, with an Area Under Curve (AUC) of 0.707 (95% CI: 0.56-0.86; p = 0.012), sensitivity of 86.11%, specificity of 57.90%, Positive Predictive Value (PPV) of 79.49%, Negative Predictive Value (NPV) of 68.75%, and Youden index of 0.44. The combination of WBC + neutrophil had a slightly higher (AUC = 0.711, 95% CI: 0.57-0.86; p = 0.011), specificity (68.42%), and PPV (81.25%), but lower sensitivity (72.22%), than the WBC count alone. A cut-off value of neutrophil at 7.46 × 109/L was effective in identifying HCA, with an AUC of 0.689 (95% CI: 0.53-0.84; p = 0.022).

DISCUSSION

Combination use of WBC+neutrophil was found to be the most accurate predictor of HCA among women with PPROM after surgery of cervical cerclage.

Cervical cerclage in twin pregnancies: obstetric and neonatal outcomes

BACKGROUND

Although there have been significant improvements in prenatal and neonatal care in recent years, twin pregnancies account for 17-20% of all preterm births and are associated with an increased risk of perinatal mortality and morbidity.

AIMS

To evaluate the contribution of cerclage to the continuation of pregnancy in twin pregnancy cases required cervical cerclage.

METHODS

Cases of twin pregnancies who performed cervical cerclage with follow-up and deliveries between January 2010 and January 2022 in the Department of Obstetrics and Gynecology, Ege University Faculty of Medicine Hospital, were retrospectively analyzed. Obstetric and neonatal outcomes were evaluated.

RESULTS

A total of 23 women who performed cervical cerclage due to cervical insufficiency in twin pregnancies were evaluated retrospectively. The mean time between cerclage placement and delivery was 12.1 ± 7 weeks, maximum prolongation was in the obstetric history-indicated cerclage group. The gestational age at delivery was 20-38 (median 30) weeks. The rate of spontaneous preterm birth at < 34, < 32, < 28, and < 24 weeks was higher in the physical examination-indicated cerclage group. Overall neonatal survival was 82.5% (n = 33/40).

CONCLUSION

The time between cerclage placement and birth were considered as an important gain for twin pregnancies at the limit of viability. Further studies are needed to better understand the role of cervical cerclage in preventing premature birth and to determine the indications for cerclage.

Comparison of two stitches versus one stitch for emergency cervical cerclage to prevent preterm birth in singleton pregnancies

OBJECTIVE

To compare the efficacy of two stitches versus one stitch in women with emergency cervical cerclage.

METHODS

A retrospective case-control study of 26 women with singleton pregnancies who underwent emergency cervical cerclage before 26 weeks. A comparison was made between patients with two stitches versus one stitch at the time of cervical cerclage placement. The primary outcome was gestational age (GA) at delivery and preterm birth (PTB) before 37, 34, 32, 28, and 24 weeks.

RESULTS

Average GA at delivery in the two-stitches group was significantly greater than in the one-stitch group (32.71 ± 5.54 weeks vs 27.99 ± 4.70 weeks, P = 0.028). There were significant decreases in the incidence of spontaneous PTB at <34 weeks and less than 32 weeks in the two-stitches group (P = 0.034; P = 0.013, respectively). The neonatal intensive care unit (NICU) admissions rate and length of stay in the NICU in the two-stitches group were significantly reduced (P = 0.035 and P = 0.018, respectively). However, there was no significant difference in neonatal mortality between the two groups.

CONCLUSION

Compared with emergency cervical cerclage placement with one stitch, the procedure with two stitches can prolong the pregnancy and improve the neonatal prognosis more effectively.

Adjunct Therapy at Time of Examination-Indicated Cervical Cerclage in Singleton Pregnancies: A Systematic Review and Meta-analysis

OBJECTIVE

Physical examination-indicated cerclage for cervical insufficiency prolongs gestation, but evidence on the addition of adjuncts to further prolong latency is limited. The aim of this systematic review and meta-analysis was to compare gestational latency between those who did and did not receive adjunct antibiotic or tocolytic therapy at the time of examination-indicated cerclage.

STUDY DESIGN

Electronic databases (1966-2020) were searched for randomized controlled trials (RCTs) and cohort studies comparing adjunct antibiotic or tocolytic use versus nonuse at time of examination-indicated cerclage, defined as placement for cervical dilation ≥1 cm, in a current singleton pregnancy. Studies including individuals with intra-amniotic infection, cerclage in place, nonviable gestation, or ruptured membranes were excluded. The primary outcome was latency from cerclage placement to delivery. Secondary outcomes included preterm birth, preterm premature rupture of membranes, birth weight, and neonatal survival. Risk of bias was assessed using standardized tools. Heterogeneity was assessed using χ 2 and I 2 tests. Results were pooled and analyzed using a random-effects model. This study is registered with The International Prospective Register of Systematic Reviews (PROSPERO) with registration no.: CRD42021216370.

RESULTS

Of 923 unique records, 163 were reviewed in full. Three met inclusion criteria: one RCT and two retrospective cohorts. The included RCT (n = 50) and one cohort (n = 142) compared outcomes with and without adjunct use of antibiotic and tocolytic, while the second cohort (n = 150) compared outcomes with and without adjunct tocolytic, with a subpopulation also receiving antibiotics. The RCT was nested within one of the cohorts, and therefore only one of these two studies was utilized for any given outcome to eliminate counting individuals twice. Risk of bias was "critical" for one cohort study, "moderate" for the other cohort study, and "some concerns" for the RCT. Gestational latency could not be pooled and meta-analyzed. Adjunct tocolytic-antibiotic therapy was not associated with a decrease in risk of preterm delivery <28 weeks (relative risk [RR] = 0.90, 95% confidence interval [CI]: 0.65-1.26; χ 2 = 0.0, I 2 = 0.0%) or neonatal survival to discharge (RR = 1.11, 95% CI: 0.91-1.35; χ 2 = 0.05, I 2 = 0.0%).

CONCLUSION

There is not enough evidence to robustly evaluate the use of adjunct tocolytics or antibiotics at time of examination-indicated cerclage to prolong latency.

KEY POINTS

· Limited data on adjunct antibiotic tocolytics at cerclage.. · Widely variable practices at time of cerclage identified.. · Role of adjunct therapies at time of examination-indicated cerclage remains unclear..

Prediction of emergency cerclage outcomes in women with cervical insufficiency: The role of inflammatory, angiogenic, and extracellular matrix-related proteins in amniotic fluid

OBJECTIVE

We aimed to determine whether various novel inflammatory, angiogenic, and extracellular matrix-related mediators in amniotic fluid (AF) can independently predict emergency cerclage outcomes in women with acute cervical insufficiency (CI).

METHODS

This was a retrospective cohort study conducted among 50 singleton pregnant women (18-25 weeks) who underwent emergency cerclage for CI and were subjected to amniocentesis. The AF samples were assayed for endoglin, endostatin, haptoglobin, insulin-like growth factor-binding protein (IGFBP)-3, -4, kallistatin, lumican, macrophage colony-stimulating factor (M-CSF), pentraxin 3, p-selectin, receptor for advanced glycation end products (RAGE), resistin, transforming growth factor beta-induced (TGFBI), and vitamin D-binding protein (VDBP) levels. Interleukin (IL)-6 levels in the AF were also measured for comparison with potential biomarkers assessed in this study. The primary endpoint was spontaneous preterm delivery (SPTD) at <34 weeks following emergency cerclage.

RESULTS

The AF levels of pentraxin 3, RAGE, and resistin were significantly higher in women who had SPTD at <34 weeks after cerclage placement (pentraxin-3: P = 0.003; RAGE: P = 0.041; and resistin; P = 0.002). In multivariate analysis, elevated AF levels of pentraxin 3 (P = 0.007) and resistin (P = 0.006), but not those of RAGE (P = 0.069), were independently associated with the occurrence of SPTD at <34 weeks after cerclage, following adjustment for baseline clinical variables (e.g., cervical dilation). The area under the curve (AUC) values of AF pentraxin 3, RAGE, and resistin for the prediction of SPTD at <34 weeks were 0.749, 0.669, and 0.770, respectively, which were similar to those of AF IL-6. However, in univariate analyses, no differences in the AF levels of endoglin, endostatin, haptoglobin, IGFBP-3, IGFBP-4, kallistatin, lumican, p-selectin, TGFBI, and VDBP were found to be associated with SPTD at <34 weeks after cerclage placement.

CONCLUSIONS

In women with acute CI, the AF levels of pentraxin 3, RAGE, and resistin could be useful novel biomarkers for predicting SPTD following emergency cerclage. However, the clinical utility of these new biomarkers should be validated in larger multicenter studies.

Elevated midtrimester maternal plasma cytokines and preterm birth in patients with cerclage

BACKGROUND

Cerclage is used for the prevention of spontaneous preterm birth; however, many patients at high risk of spontaneous preterm birth who have a cerclage in place eventually deliver before term. Although inflammation, measured by biomarkers (eg, cytokines), is a known risk factor for preterm delivery, evaluation of inflammation to determine pregnancy outcomes among patients with cerclage is poorly understood.

OBJECTIVE

We sought to examine levels of maternal plasma inflammatory cytokines in the midtrimester among asymptomatic patients with a cervical cerclage (placed for any indication, including history, ultrasound, and examination indications) to evaluate the association between cytokine levels and preterm birth.

STUDY DESIGN

This was a prospective cohort study of singleton, nonanomalous pregnancies who had a cerclage placed at <24 weeks of gestation from 2015 to 2018 at a single tertiary institution. Maternal plasma was collected perioperatively whenever possible. A custom magnetic bead Luminex cytokine assay was used to measure plasma inflammatory cytokine levels from these stored samples. The primary outcome was preterm birth at <37 weeks of gestation. A statistical cut point was calculated for each cytokine level to assess its optimal sensitivity and specificity for spontaneous preterm birth prediction. Patients were classified as having a "high" or "low" result for each cytokine based on this cut point. Receiver operating characteristic curve analysis was performed to estimate sensitivity, specificity, and positive and negative predictive values for spontaneous preterm birth prediction. Cox proportional-hazards regression modeled the association between the number of "high" inflammatory cytokines and gestational age at delivery, adjusting for confounders. Additional analyses were performed on the subgroup of patients with history-indicated cerclage and those with an ultrasound- or examination-indicated cerclage.

RESULTS

A total of 43 patients participated in this study: 20 (46.5%) had spontaneous preterm birth (median, 30.9 weeks of gestation; interquartile range, 28.4-35.0). Plasma samples were collected at a median of 0 (interquartile range, -2 to 17) days concerning cerclage placement and a median of 18 (interquartile range, 13-21) weeks of gestation. Based on the statistical cut point for each cytokine level, 7% of patients had zero, 20.9% had 1, 18.6% had 2, 20.9% had 3, and 32.6% had ≥4 "high" cytokine results. Each additional "high" cytokine level was associated with earlier delivery (hazard ratio, 1.51; 95% confidence interval, 1.25-1.81) even after controlling for ultrasound- or examination-indication for cerclage (hazard ratio, 1.73; 95% confidence interval, 0.95-3.15). The presence of ≥4 "high" cytokine levels was 70% sensitive and 74% specific for predicting spontaneous preterm birth (area under the curve, 0.846; 95% confidence interval, 0.728-0.964; positive predictive value, 70%; negative predictive value, 73.9%).

CONCLUSION

Among patients with a cervical cerclage, elevated midtrimester maternal plasma cytokine profiles were associated with subsequent preterm birth and can estimate the probability of preterm birth. Confirmation and refinement of this noninvasive panel may provide insight into improved selection of individuals who may benefit from cerclage placement and investigation of therapeutic strategies to mitigate midpregnancy inflammation.

A Three-Step Procedure for Emergency Cerclage: Gestational and Neonatal Outcomes

(1) Background: The objective of our prospective observational study was to evaluate a new technique for emergency cerclage, which was performed on a cohort of patients with cervical incompetence in the second trimester. (2) Methods: 26 pregnant women presented at 15 to 24 weeks of gestation with cervical dilatation and bursa prolapse. A new emergency cerclage was performed using a technique consisting of the first cerclage in a tobacco bag and a second occlusive cerclage located inferiorly to the first. The technique is concluded with the performance of a cervical cleisis when vaginal bag prolapse is present, and this overall procedure is called the three-step procedure for emergency cerclage (TSEC). (3) Results: To assess its effectiveness, we measured the latency from procedure to delivery, pregnancy duration, infant birth weight, and rate of premature amniorrhexis. The mean latency from procedure to delivery was 14 weeks + 6 days, the mean weight of newborns was 2550 g and the mean gestational age at delivery was 35 weeks. The neonatal survival rate was 95.8%. The rate of premature amniorrhexis (<34 weeks gestational age) was 8.3% (two cases) with successful perinatal outcomes. There were significant differences (p < 0.05) between groups. A multivariate regression model showed that the best variables for predicting the latency to delivery were the cervical dilatation at diagnosis, use of the three-step cerclage, cervical length after the procedure, and gestational age at diagnosis. (4) Conclusions: The excellent results obtained with the TSEC procedure in terms of the latency from the procedure to delivery, gestational age at delivery, birth weight, and having few reported complications highlight the importance of collecting new data on this promising novel procedure.

Cervical Cerclage: A Review and Rethinking of Current Practice

Importance

Cervical insufficiency (CI) is a serious complication of pregnancy, which can cause preterm birth. Identifying how to most effectively treat CI has the potential to maximize neonatal survival in this population of women.

Objective

To determine whether transabdominal cervical cerclage should be offered as a first-line treatment option in high-risk women.

Evidence Acquisition

An electronic literature search for relevant studies was conducted using keywords (CI, cervical cerclage) on the MEDLINE database.

Results

Although transabdominal cerclage (TAC) is reserved as a second-line treatment option over transvaginal cerclage (TVC), it has some advantages over TVC: a higher placement of the suture at the level of the cervicoisthmic junction; avoidance of placement of foreign material in the vagina, in turn, reducing risk of infection and inflammation, which can propagate preterm labor; and the option to leave the suture in place for future pregnancies. Systematic review evidence offers TAC as a more effective procedure to TVC in reducing preterm birth and maximizing neonatal survival. Although TAC is a slightly more complex procedure compared with TVC, advances in minimally invasive surgery now allow gynecologists to perform this more effective procedure laparoscopically and therefore without the added morbidity of open surgery but with the same if not better outcomes.

Conclusions

Laparoscopic TAC can provide a more effective treatment option for CI without the added burdens of open abdominal surgery.

Relevance

Our article highlights future directions for study in the area of cervical cerclage and refinement of existing practices.

The Short Cervix: A Critical Analysis of Diagnosis and Treatment

A short cervix in the second trimester is a significant risk factor for spontaneous preterm birth, preterm prelabor rupture of membranes, and subsequent adverse perinatal outcome. The pathophysiology is complex and multifactorial with inflammatory and/or infectious processes often involved. Biomarkers have been developed in an effort to predict preterm birth with varying degrees of success. The treatment options of cerclage, progesterone, pessary, and combination therapy are reviewed. Evidence-based protocols are summarized for singleton and multiple gestation.

Physical examination-indicated cerclage in twin pregnancy: a randomized controlled trial

BACKGROUND

Women with twin pregnancies and a dilated cervix in the second trimester are at increased risk of pregnancy loss and early preterm birth; there is currently no proven therapy to prevent preterm birth in this group of women.

OBJECTIVE

This study aimed to determine whether physical examination-indicated cerclage reduces the incidence of preterm birth in women with a diagnosis of twin pregnancies and asymptomatic cervical dilation before 24 weeks of gestation.

STUDY DESIGN

Multicenter, parallel group, open-label, randomized controlled trial of women with twin pregnancies and asymptomatic cervical dilation of 1 to 5 cm between 16 weeks 0/7 days of gestation and 23 weeks 6/7 days of gestation were enrolled from July 2015 to July 2019 in 8 centers. Eligible women were randomized in a 1:1 ratio into either cerclage or no cerclage groups. We excluded women with monochorionic-monoamniotic twin pregnancy, selective fetal growth restriction, twin-twin transfusion syndrome, major fetal malformation, known genetic anomaly, placenta previa, signs of labor, or clinical chorioamnionitis. The primary outcome was the incidence of preterm birth at <34 weeks of gestation. Secondary outcomes were preterm births at <32, <28, and <24 weeks of gestation, interval from diagnosis to delivery, and perinatal mortality. Data were analyzed by intention-to-treat methods.

RESULTS

After an interim analysis was performed, the Data and Safety Monitoring Board recommended stopping the trial because of a significant decrease in perinatal mortality in the cerclage group. We randomized 34 women, with 4 women being excluded because of expired informed consent. A total of 17 women were randomized to physical examination-indicated cerclage and 13 women to no cerclage. Whereas 4 women randomized to cerclage did not receive the surgical procedure, no women in the no cerclage group received cerclage. Maternal demographics were not significantly different. All women in the cerclage group also received indomethacin and antibiotics. When comparing the cerclage group vs the no cerclage group, the incidence of preterm birth was significantly decreased as follows: preterm birth at <34 weeks of gestation, 12 of 17 women (70%) vs 13 of 13 women (100%) (risk ratio, 0.71; 95% confidence interval, 0.52-0.96); preterm birth at <32 weeks of gestation, 11 of 17 women (64.7%) vs 13 of 13 women (100%) (risk ratio, 0.65; 95% confidence interval, 0.46-0.92); preterm birth at <28 weeks of gestation, 7 of 17 women (41%) vs 11 of 13 women (84%) (risk ratio, 0.49; 95% confidence interval, 0.26-0.89); and preterm birth at <24 weeks of gestation, 5 of 17 women (30%) vs 11 of 13 women (84%) (risk ratio, 0.35; 95% confidence interval, 0.16-0.75). The mean gestational age at delivery was 29.05±1.7 vs 22.5±3.9 weeks (P<.01), respectively; the mean interval from diagnosis of cervical dilation to delivery was 8.3±5.8 vs 2.9±3.0 weeks (P=.02), respectively. Perinatal mortality was also significantly reduced in the cerclage group compared with the no cerclage group as follows: 6 of 34 women (17.6%) vs 20 of 26 women (77%) (risk ratio, 0.22; 95% confidence interval, 0.1-0.5), respectively.

CONCLUSION

In women with twin pregnancies and asymptomatic cervical dilation before 24 weeks of gestation, a combination of physical examination-indicated cerclage, indomethacin, and antibiotics significantly decreased preterm birth at all evaluated gestational ages. Most importantly, cerclage in this population was associated with a 50% decrease in early preterm birth at <28 weeks of gestation and with a 78% decrease in perinatal mortality.

Outcomes of ultrasound and physical-exam based cerclage: assessment of risk factors and the role of adjunctive progesterone in preventing preterm birth-a retrospective cohort study

OBJECTIVE

To assess outcomes of ultrasound and physical examination-based cerclage performed at mid to late second trimester and to assess the potential added value of progesterone treatment combined with cerclage for preventing preterm birth.

STUDY DESIGN

A retrospective cohort study of women who underwent cerclage in a university-affiliated tertiary medical center (2012-2018). Inclusion criteria included only ultrasound-based cerclage and physical examination-based cerclage. Women who underwent history-based cerclage or multiple gestations were excluded. Study groups were stratified by previous PTB < 37 weeks and other risk factors for PTB. Primary outcome was the incidence of preterm birth < 35 weeks of gestation. Secondary outcomes included the potential added value of progesterone treatment and neonatal outcome.

RESULTS

Sixty-nine women underwent cervical cerclage placement between 16-23 weeks of gestation. All women had short cervix (cervical length of < 25 mm) at presentation. Indications for cerclage placement included: 29% previous PTB, 32% prior cervical interventions (history of at least one D&C, hysteroscopy or cold-knife conization in the past), 22% had cervical dilatation > 1 cm at presentation, 12% due to failure of progesterone treatment defined as continued cervical shortening after 14 days of progesterone treatment, and 5% had other indications. Overall, 42 women (61%) gave birth at term. 27 women (39%) delivered prior to 37 weeks of gestation, of them, 20 women (29%) gave birth prior to 35 weeks. Overall median gestational age at delivery was 35 + 5 ± 4.7 weeks. Cervical dilatation at presentation of > 1 cm was associated with an increased risk for PTB < 35 weeks (OR 3.57, CI 1.43-30.81, p = 0.036). Previous PTB, prior cervical interventions and extent of cervical shortening at presentation did not increase the risk of PTB. Progesterone treatment in addition to cerclage did not result in a decreased risk for PTB < 35 weeks of gestation (OR 2.83, CI 0.58-13.89, p = 0.199).

CONCLUSION

Late second trimester cerclage is a practical measure for preventing PTB in cases of asymptomatic cervical shortening. Our study did not find adjunctive benefit for progesterone treatment with physical or ultrasound-based cerclage in reducing the rate PTB.

Cervical elastography using E-cervix for prediction of preterm birth in singleton pregnancies with threatened preterm labor

Objective: E-Cervix™ (WS80A; Samsung, Seoul, Korea) elastography is a recent quantification tool to measure the stiffness of the cervix using strain elastography. The aim of this study was to evaluate the prediction performance of E-cervix for preterm birth in singleton gestation with threatened preterm labor (PTL).Methods: This was a cohort study of singleton pregnancies without prior preterm birth presenting to obstetrics triage for threatened PTL between 23 0/7 and 33 6/7 week who received screening for PTL with transvaginal ultrasound cervical length (TVU CL) and cervical elastography with E-cervix at the time of triage. Cervical elastography parameters were examined and compared between women who delivered preterm and those who did not. The quantification of cervical strain was calculated by a data analysis system that directly analyses raw data from the region of interest (ROI) and described as hardness ratio (HR), mean strain level within 1 cm from internal os (IOS) and external os (EOS).Results: Ninety-five singleton pregnancies without prior preterm birth and with threatened PTL between 23 0/7 and 33 6/7 week of gestation were included in the study. Forty-two (44.2%) had cervical length <25 mm, and were admitted for true PLT. Out of the 53 women with cervical length ≥25 mm, 40 (75.5%) were discharged, and 13 (24.5%) were admitted. Women with threatened PTL but without true PTL, had significantly higher HR compared to those with true PTL (49.0 ± 20.9% versus 34.8 ± 19.6%; p < .01), and significantly lower stiffness of cervical IOS and EOS. Women who delivered preterm had significantly lower HR compared to those who did not delivery preterm, in overall cohort, and in the subset of only women with true PTL. Incidences of HR < 50% and <35% were statistically significantly higher in women who delivered preterm compared to those who did not (p < .01).Conclusions: Cervical elastography with E-cervix may be useful for the assessment of women presenting to obstetrics triage for threatened PTL. Women with low HR, especially with HR less than 50 or 35%, are at increased risk of PTB.Condensation: Women who delivered preterm had significantly lower HR compared to those who did not delivery preterm and significantly lower IOS and EOS, in overall cohort, and in the subset of women with true PTL. Incidences of HR < 50% and <35% were statistically significantly higher in women who delivered preterm compared to those who did not (p < .01).Key message: Cervical elastography with E-cervix may be useful for the assessment of women presenting to obstetrics triage for threatened PTL.

A Novel Cerclage Insertion: Modified Laparoscopic Transabdominal Cervical Cerclage with Transvaginal Removing (MLTCC-TR)

STUDY OBJECTIVE

To report on our center's experience of a novel modified approach for laparoscopic cervical cerclage and to evaluate its safety and efficacy preliminarily.

DESIGN

Retrospective descriptive study.

SETTING

Single academic institution.

PATIENTS

Pregnant and nonpregnant women who underwent the modified laparoscopic transabdominal cervical cerclage with transvaginal removing (MLTCC-TR) from June 2016 to April 2019. Eligible participants had multiple adverse obstetric histories or the short cervix and were not suitable for a second transvaginal cerclage.

INTERVENTIONS

Preconceptional or postconceptional MLTCC-TR.

MEASUREMENTS AND MAIN RESULTS

A total of 24 participants (including 3 first-trimester singleton pregnant women) underwent the MLTCC-TR, giving birth to 27 infants. Among 21 women who underwent preconceptional cerclage, 26 cases of postoperational pregnancies were noted, and the incidence of term labor was 73.07%, which was significantly higher than that in the precerclage group (p <.001). Their mean gestational age at delivery was 37.21 ± 5.05 weeks. Among 3 cases of postconceptional cerclage, the mean gestational age at cerclage was 10.90 ± 2.61 weeks, and all of them had term delivery. The overall neonatal survival rate was 100% (27/27), of which 81.48% (22/27) were term infants. There were no severe perioperative complications directly related to the insertion of cerclage.

CONCLUSION

Our new approach of MLTCC-TR may be a relatively effective, feasible, and safe treatment for cervical insufficiency. It may be considered as an acceptable alternative to the traditional laparoscopic cervical cerclage with its superiority of transvaginal removing.

Correlation between gestational age and level of sensory block in spinal anesthesia

BACKGROUND AND OBJECTIVES

To identify a specific correlation between progression of gestational age and level of sensory block in spinal anesthesia in patients undergoing cervical cerclage.

METHODS

The medical records of patients who underwent cervical cerclage under spinal anesthesia using hyperbaric bupivacaine between March 2016 and May 2018 were retrospectively reviewed. The primary outcome measure was the correlation between gestational age and sensory block level of spinal anesthesia. Secondary outcomes included the correlations between gestational age and reduction in blood pressure and length of the postanesthesia care unit (PACU) stay. The Pearson correlation test, partial correlation test, and linear regression were used to identify relationships and to adjust for confounding variables.

RESULTS

Of the 261 cases reviewed, there was a linear and significant correlation between gestational age and sensory block level, reduction in systolic blood pressure during surgery, reduction in systolic blood pressure during PACU, and length of PACU stay, after adjusting for confounding factors (partial correlation coefficient=0.71, p<0.001; 0.27, p<0.001; 0.25, p<0.001; 0.21, p=0.001, respectively). A 1-day increase in gestational age corresponded to an increase of 0.04 dermatomes in sensory block level (95% CI 0.035 to 0.045, p<0.001).

CONCLUSION

Results demonstrated that as the gestational age progressed, sensory block level increased, blood pressure was decreased, and length of PACU stay increased after spinal anesthesia. Sensory block increased by 0.28 dermatomes when the pregnancy progressed 1 week. Further controlled prospective studies are needed to support this relationship.

TRIAL REGISTRATION NUMBER

KCT0000538.

Comparison of obstetrical outcomes in patients undergoing cerclage with or without amniocentesis

OBJECTIVE

We sought to compare the obstetrical outcomes in patients who underwent midtrimester cerclage placement with or without prior amniocentesis in a single center cohort.

METHODS

A retrospective medical record review in a single academic institution was undertaken of all patients who underwent either an exam or ultrasound indicated cerclage. This group was then divided into two groups: amniocentesis or no amniocentesis groups. Detailed maternal data was abstracted from the prenatal and hospital records. Amniocentesis fluid specimens were sent for Gram stain, aerobic and anaerobic bacterial culture, including mycoplasma and ureaplasma, as well as for glucose. Comparisons were performed utilizing Parametric 2-sample t-test for continuous variables and Fisher's exact test was utilized to compare categorical variables.

RESULTS

A total of 160 patients who underwent a cerclage were utilized for comparison. Sixty-five patients who had an amniocentesis performed prior to the cerclage were compared with 95 patients who underwent a cerclage without an amniocentesis. None of the amniocentesis results were positive for infection in those that received a cerclage. Patients that had an amniocentesis before cerclage were found to have an earlier gestational age at time of the procedure (20.30 ± 2.29 weeks versus 21.32 ± 1.81 weeks, p < .001), a shorter cervical length on presentation (0.93 ± 0.61 cm versus 1.45 ± 0.66 cm, p < .001), delivered at an earlier gestational age (GA 32.2 [30.3 to 34.2] versus 36.3 [35.2 to 37.3] weeks, p < .001) with shorter time from cerclage placement until delivery (13.9 [0.0 to 24.0] versus 16.3 [0.3 to 23.2] weeks, p = .010). The rates of chorioamnionitis and PPROM were significantly higher in the amniocentesis group (17 versus 2%, p = .0008 and 26 versus 13%, p = .03 respectively). Five patients who underwent an amniocentesis did not receive a cerclage, with one having a positive Gram stain and culture.

CONCLUSION

Amniocentesis use prior to cerclage placement in this single institution cohort was utilized in patients who presented earlier in gestation with shorter cervical length and more cervical dilation. The severity of presentation was the determining factor in the decision to perform an amniocentesis prior to cerclage placement, and, because of this difference in severity, outcomes for the amniocentesis group were predictably worse than those who did not undergo amniocentesis.

A comparison of emergency and therapeutic modified Shirodkar cerclage: an analysis of 38 consecutive cases

Objective:

To compare the maternal and neonatal outcomes of patients with emergency versus therapeutic cerclage.

Materials and Methods:

The study included 38 female patients who underwent cervical cerclage using the modified Shirodkar method in the Obstetrics and Gynecology Clinics of Düzce University Medical Faculty Hospital and Düzce Atatürk State Hospital.

Results:

The operating time for the emergency cerclage group was significantly longer than that of the therapeutic group (30.40 minutes vs 19.85 minutes, p=0.001). Following the cerclage procedure, the cervical length was longer in the therapeutic cerclage group [29.90 millimeters (mm) vs. 22.45 mm, p=0.001]. The cerclage to birth interval was also longer in the therapeutic group (91 vs. 138 days).

Conclusion:

In comparison with therapeutic cerclage, the total duration of pregnancy after emergency cerclage is shorter, and newborns have a greater need for intensive care. Both methods, however, protect against advanced prematurity, which causes neonatal loss.

Efficacy of an Emergency Cervical Cerclage Using Absorbable Monofilament Sutures

Introduction

Although nonabsorbable woven tape has been widely used for cervical cerclage, technical difficulties that can occur with an effaced cervix because of the thickness of the tape, and the risks of local infection are two major concerns. This study investigated perinatal outcomes of pregnancies involving an emergency cervical cerclage using absorbable monofilament polydioxanone sutures, which is a narrow thread and protects against bacterial infection.

Materials and Methods

We performed a chart review of patients who underwent emergency McDonald cerclage with polydioxanone sutures at our institution between 2007 and 2015. Gestational age at delivery, duration between cerclage and delivery, and neonatal prognosis were evaluated as primary outcomes.

Results

Among the 23 patients (18 singleton and five twin pregnancies) evaluated, ultrasound-indicated (progressive cervical length shortening) were eight (35%) and physical examination-indicated (fetal membranes that prolapsed into the vagina or dilated cervix) were 15 patients (65%). The median gestational age at cerclage was 22⁺³ weeks (range, 17⁺⁵ to 25⁺³ weeks). Postoperative spontaneous abortion occurred in only one patient. The median gestational age at delivery was 32⁺⁵ weeks (range, 20⁺⁵ to 40⁺⁶ weeks). Extremely preterm delivery before 28 weeks of gestation occurred in four (17%) cases. Full-term delivery was achieved in 10 (42%) cases. The duration between cerclage and delivery ranged from 5 to 136 days (median, 77 days). Except for one case of spontaneous abortion, all newborns survived till hospital discharge.

Conclusions

Although our series included some patients at high risk for spontaneous abortion and preterm delivery, satisfactory prolongation and favorable neonatal outcomes were achieved for most patients by using absorbable monofilament sutures, thus suggesting the efficacy of this type of suture for emergency cervical cerclage.

McDonald versus modified Shirodkar rescue cerclage in women with prolapsed fetal membranes

Purpose: We compared the efficacy of modified Shirodkar and McDonald rescue cerclage techniques in women with singleton pregnancies.Methods: The study sample included 47 women who presented at two tertiary hospitals in Turkey from 2008 to 2017 and underwent rescue cerclage due to cervical incompetence and cervical dilatation with fetal membranes prolapsed into the vagina. The outcomes were compared by cerclage technique used, Shirodkar or McDonald.Results: The McDonald cerclage was applied in 27 cases, and modified Shirodkar cerclage in 20 cases. A longer cerclage-to-birth interval (83.8 ± 37.6 vs. 63.7 ± 38.9 days) and later gestational age at delivery (33 vs. 31 weeks) were observed with the Shirodkar cerclage, although these differences were not statistically significant (p = .08 and .63, respectively). Both groups had similar delivery rates after 28, 32, and 37 weeks (p = .20, .15, and .25, respectively), whereas the modified Shirodkar technique resulted in a higher rate of live births although these differences were not statistically significant (85% vs. 63%, p = .09).Conclusion: The effects of the McDonald and modified Shirodkar cerclage procedures on prolonging pregnancy and improving the live birth rate were similar. Therefore, either technique can be applied to prevent neonatal loss due to advanced prematurity.

Knot positioning during McDonald cervical cerclage, does it make a difference? A cohort study

Objective: To study the effect of McDonald cerclage knot position on the different maternal and neonatal outcomes. Methods: This historical cohort study included women with singleton pregnancy who had a prophylactic McDonald cervical cerclage between 1 May 2010 and 31 September 2017. Maternal and neonatal outcome parameters were compared between the anterior and posterior knot cerclage procedures. The primary outcome measure was the rate of term birth. Results: 550 Women had a prophylactic McDonald cervical cerclage, 306 with anterior knot (Group A) and 244 with posterior knot (Group B). There were no statistically significant differences regarding gestational age (GA) at delivery (36.3 ± 4.2 versus 35.8 ± 5.3 for groups A and B respectively), term birth rate, post-cerclage cervical length, symptomatic vaginitis, urinary tract infection, difficult cerclage removal and cervical lacerations. Similarly, there were no statistically significant differences as regards the studied neonatal outcomes including take home babies, neonatal intensive care admission, respiratory distress syndrome and neonatal sepsis. Survival analysis on GA at delivery demonstrated no statistically significant difference as regards the proportion of term deliveries in the anterior and posterior knot cerclage groups (log-rank test p-value = .478). Conclusions: Knot positioning during McDonald cervical cerclage, anteriorly or posteriorly, didn't significantly impact the studied maternal and neonatal outcomes.

McDonald versus Shirodkar cervical cerclage for the prevention of preterm birth: impact of body mass index

Objective: To compare obstetrical outcomes on women undergoing a McDonald or Shirodkar cerclage and to estimate the impact of maternal body mass index (BMI) on these outcomes. Methods: We conducted a retrospective review of the medical records of all women with singleton pregnancies who underwent placement of a McDonald or Shirodkar cerclage at St. Francis Hospital from January 2008 to October 2013. The subjects were categorized based on BMI groups (normal: less than 25 kg/m², overweight: 25-29 kg/m², obese: 30 kg/m² or more). The primary outcome was gestational age at delivery. Statistical analyses included chi-square, Student's t-test, and multivariable regression analysis. Results: Of 95 women, 47 (49.5%) received a Shirodkar, and 48 (50.5%) a McDonald cerclage. 16 women (16.8%) were categorized as normal weight, 35 (36.8%) as overweight, and 44 (46.3%) as obese. Gestational age at delivery differed significantly by group, decreasing with each categorical increase in BMI (normal: 39.0 ± 0.3 weeks; overweight: 36.6 ± 0.7 weeks; obese: 33.0 ± 1.1 weeks; p < .01). Overall, women receiving a Shirodkar cerclage had significantly longer pregnancies than women with a McDonald cerclage (36.7 ± 0.6 weeks versus 33.9 ± 1.0 weeks; p = .02). However, analysis showed a significant interaction between weight status and gestational age at delivery. Obese women had significantly longer pregnancies when they received a Shirodkar cerclage versus a McDonald cerclage (32.6 ± 1.0 weeks versus 28.8 ± 0.9 weeks; p < .01). However, there was no significant difference in gestational age at delivery between women categorized as normal/overweight (Shirodkar: 33.5 ± 0.9 weeks; McDonald: 32.9 ± 0.9 weeks; p = .63). Conclusions: Compared to obese women receiving a McDonald cerclage, obese women receiving a Shirodkar cerclage had significantly longer pregnancies. No significant differences in pregnancy duration were found in normal/overweight women regardless of cerclage technique. Pregnancy duration in obese women receiving a Shirodkar cerclage was similar to the pregnancy duration of normal/overweight women.

A comparison of pregnancy outcome of modified transvaginal cervicoisthmic cerclage performed prior to and during pregnancy

PURPOSE

To compare the pregnancy outcome of the modified transvaginal cerclage performed preconception and during pregnancy.

METHODS

A retrospective trial was carried out in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China. A total of 604 women with cervical incompetence underwent the cerclage, and the time of the operation was decided by the patients or depended on when the patient presented. Main outcome measures were the gestational age and the fetal outcome.

RESULTS

After the cerclage, the mean gestational age at delivery and the term delivery rate were significantly higher in history-indicated conception cerclage compared to preconception cerclage (36.8 ± 3.7 vs 35.8 ± 4.7, p < 0.01; 76.1 vs 66.9%, p < 0.05). The mean gestational age at delivery and the term delivery rate were significantly higher in ultrasound-indicated compared to physical examination-indicated conception cerclage (35.0 ± 5.7 vs 31.0 ± 5.5, p < 0.01; 63.2 vs 23.3%, p < 0.001). The fetal survival rate had no difference in these two comparisons, respectively.

CONCLUSIONS

The modified transvaginal cervicoisthmic cerclage is a promising and safe technique to improve obstetric outcomes in women with cervical incompetence in different cerclage indications, and history-indicated conception cerclage appears to have better pregnancy outcome.

Effect of Cervical Pessary on Spontaneous Preterm Birth in Women With Singleton Pregnancies and Short Cervical Length: A Randomized Clinical Trial

IMPORTANCE

Spontaneous preterm birth is a major cause of perinatal morbidity and mortality. It is unclear if a cervical pessary can reduce the risk of spontaneous preterm delivery.

OBJECTIVE

To test whether in asymptomatic women with singleton pregnancies and no prior spontaneous preterm birth but with short cervical length on transvaginal ultrasound, use of a cervical pessary would reduce the rate of spontaneous preterm birth at less than 34 weeks of gestation.

DESIGN, SETTING, AND PARTICIPANTS

Parallel-group, nonblinded, randomized clinical trial conducted from March 1, 2016, to May 25, 2017, at a single center in Italy. Asymptomatic women with singleton gestations, no previous spontaneous preterm births, and cervical lengths of 25 mm or less at 18 weeks 0 days to 23 weeks 6 days of gestation were eligible.

INTERVENTIONS

Patients were randomized 1:1 to receive either cervical pessary (n = 150) or no pessary (n = 150). The pessary was removed between 37 weeks 0 days and 37 weeks 6 days of gestation or earlier if clinically indicated. The control group received standard care. For cervical length of 20 mm or shorter, women in both groups were prescribed vaginal progesterone, 200 mg/d, until 36 weeks 6 days of gestation. No bed rest or activity restriction was recommended.

MAIN OUTCOMES AND MEASURES

The primary end point was spontaneous preterm birth at less than 34 weeks of gestation. Secondary outcomes were adverse events.

RESULTS

Among 300 women who were randomized (mean age, 29 [SD, 6.3] years; mean gestational age, 22 [SD, 1.3] weeks), 100% completed the trial. The primary end point occurred in 11 women (7.3%) in the pessary group and 23 women (15.3%) in the control group (between-group difference, -8.0% [95% CI, -15.7% to -0.4]; relative risk, 0.48 [95% CI, 0.24-0.95]). During follow-up, the pessary group had a higher rate of increased or new vaginal discharge (86.7% vs 46.0%; between-group difference, +40.7% [95% CI, +30.1%-+50.3%]; relative risk, 1.88 [95% CI, 1.57-2.27]).

CONCLUSIONS AND RELEVANCE

Among women without prior spontaneous preterm birth who had asymptomatic singleton pregnancies and short transvaginal cervical length, use of a cervical pessary, compared with no pessary use, resulted in a lower rate of spontaneous preterm birth at less than 34 weeks of gestation. The results of this single-center, nonblinded study among selected pregnant women require confirmation in multicenter clinical trials.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02716909.

Current options for mechanical prevention of preterm birth

Cervical insufficiency can be defined by a combination of obstetric history, cervical dilation on exam, and/or short cervical length in women with prior preterm birth. Options for mechanical intervention include cerclage and pessary. There is evidence to support the benefit of a cervical cerclage in women with singleton gestations who have a diagnosis of cervical insufficiency either based on second trimester painless cervical dilatation leading to recurrent early preterm births, or a history of early spontaneous preterm birth and a second trimester transvaginal ultrasound short cervical length or cervical dilation on exam. For women with multiple gestations, the benefit of a cerclage is uncertain, and further study is warranted. The pessary has also been studied for mechanical prevention of preterm birth in various populations, however the results so far have been mixed and warrants further study prior to routine use.

Cerclage for sonographic short cervix in singleton gestations without prior spontaneous preterm birth: systematic review and meta-analysis of randomized controlled trials using individual patient-level data

OBJECTIVE

The aim of this systematic review and meta-analysis was to quantify the efficacy of cervical cerclage in preventing preterm birth (PTB) in asymptomatic singleton pregnancies with a short mid-trimester cervical length (CL) on transvaginal sonography (TVS) and without prior spontaneous PTB.

METHODS

Electronic databases were searched from inception of each database until February 2017. No language restrictions were applied. All randomized controlled trials (RCTs) of asymptomatic singleton pregnancies without prior spontaneous PTB, found to have short CL < 25 mm on mid-trimester TVS and then randomized to management with either cerclage or no cerclage, were included. Corresponding authors of all the included trials were contacted to obtain access to the data and perform a meta-analysis of individual patient-level data. Data provided by the investigators were merged into a master database constructed specifically for the review. Primary outcome was PTB < 35 weeks. Summary measures were reported as relative risk (RR) with 95% CI. The quality of the evidence was assessed using the GRADE approach.

RESULTS

Five RCTs, including 419 asymptomatic singleton gestations with TVS-CL < 25 mm and without prior spontaneous PTB, were analyzed. In women who were randomized to the cerclage group compared with those in the control group, no statistically significant differences were found in PTB < 35 (21.9% vs 27.7%; RR, 0.88 (95% CI 0.63-1.23); I²  = 0%; five studies, 419 participants), < 34, < 32, < 28 and < 24 weeks, gestational age at delivery, preterm prelabor rupture of membranes (PPROM) and neonatal outcomes. In women who received cerclage compared with those who did not, planned subgroup analyses revealed a significantly lower rate of PTB < 35 weeks in women with TVS-CL < 10 mm (39.5% vs 58.0%; RR, 0.68 (95% CI, 0.47-0.98); I²  = 0%; five studies; 126 participants) and in women who received tocolytics (17.5% vs 32.7%; RR, 0.54 (95% CI, 0.31-0.93); I²  = 0%; four studies; 169 participants) or antibiotics (18.3% vs 31.5%; RR, 0.58 (95% CI, 0.33-0.98); I²  = 0%; three studies; 163 participants) as additional therapy to cerclage. The quality of evidence was downgraded two levels because of serious imprecision and indirectness, and therefore was judged as low.

CONCLUSIONS

In singleton gestations without prior spontaneous PTB but with TVS-CL < 25 mm in the second trimester, cerclage does not seem to prevent preterm delivery or improve neonatal outcome. However, in these pregnancies, cerclage seems to be efficacious at lower CLs, such as < 10 mm, and when tocolytics or antibiotics are used as additional therapy, requiring further studies in these subgroups. Given the low quality of evidence, further well-designed RCTs are needed to confirm the findings of this study. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Vaginal Cerclage: Preoperative, Intraoperative, and Postoperative Management

The role of the cerclage procedure has expanded from its initial application as treatment or prevention of cervical insufficiency to prevention of recurrent spontaneous preterm birth. Although recent prospective studies have clarified the indications for cerclage, additional prospective studies are needed to help define optimal perioperative management. Herein, we review the current data to provide the clinician with the most evidence-based approach to managing patients who require cerclage.

[Does post operative sonographic position of preventive cervical cerclage affect gestational age at birth?]

OBJECTIVE

To evaluate whether the position of preventive cerclage determined by immediate postoperative transvaginal cervical ultrasound is predictive of preterm birth.

METHODS

A single-center retrospective study conducted between 1 August 2007 and 31 December 2015 in a maternity type III who included women carrying out for a single pregnancy and who receive a McDonald preventive cerclage. Measurements of internal os-stitch, stitch-external os and the total length of the cervix were performed during immediate postoperative transvaginal cervical ultrasound. The position of the cerclage has been defined by the internal os-stitch/cervical length and stitch-external os/cervical length ratios. Measures were compared according to gestational age at delivery (before and after 32weeks and before and after 37weeks).

RESULTS

During the study period, 379 single pregnancies that received a McDonald preventive cerclage were included. The mean gestational age at delivery was 37.6±3.6 SA. The rate of preterm birth before 32weeks was 6.5% (n=25) and before 37weeks was 16.6% (n=63). There was no significant difference in the internal ost-stitch/cervical length ratios and the stitch-external ost/cervical length ratio between women who delivered before and after 32weeks or for those who delivered before and after 37weeks. The areas under the ROC curves for the various parameters studied were all less than or equal to 0.6.

CONCLUSIONS

The position of cerclage determined by transvaginal cervical ultrasound in immediate post operative does not seem predictive of the risk of premature birth.

Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation: retrospective cohort study

BACKGROUND

Cervical dilation in the second trimester is associated with a greater than 90% rate of spontaneous preterm birth and a poor perinatal prognosis.

OBJECTIVE

To compare the perinatal outcomes of twin pregnancies with dilated cervix in women who underwent either cerclage or expectant management.

STUDY DESIGN

Retrospective cohort study of asymptomatic twin pregnancies identified with cervical dilation of ≥1 cm at 16-24 weeks (1997-2014) at 7 institutions. Exclusion criteria were genetic or major fetal anomaly, multifetal reduction at >14 weeks, prior cerclage placement, monochorionic-monoamniotic placentation, active vaginal bleeding, labor, chorioamnionitis, elective termination of pregnancy, or medically indicated preterm birth. The primary outcome was incidence of spontaneous preterm birth at <34 weeks. Secondary outcomes were incidence of spontaneous preterm birth at <32 weeks, <28 weeks, and <24 weeks; perinatal mortality; and composite adverse neonatal outcome (respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis).

RESULTS

A total of 76 women with twin pregnancy with dilated cervix of 1.0-4.5 cm were managed with either cerclage (n = 38) or expectant management (n = 38). Demographic characteristics were not significantly different. Analysis was adjusted for amniocentesis and vaginal progesterone use. In the cerclage group, 29 women (76%) received prophylactic indomethacin and 36 (94%) received prophylactic antibiotics, whereas the expectant management group did not. Interval from time at diagnosis of open cervix to delivery in the cerclage group was 10.46 ± 5.6 weeks vs 3.7 ± 3.2 weeks in the expectant management group, with a mean difference of 6.76 weeks (95% confidence interval [CI], 4.71-8.81). There were significant decreases in spontaneous preterm birth at <34 weeks (52.6% vs 94.7%; adjusted odds ratio [aOR], 0.06; 95% CI, 0.03-0.34), at <32 weeks (44.7% vs 89.4%; aOR, 0.08; 95% CI, 0.03-0.34); at <28 weeks (31.6% vs 89.4%; aOR, 0.05; 95% CI, 0.01-0.2); and at <24 weeks (13.1% vs 47.3%; aOR, 0.17; 95% CI, 0.05-0.54). There were also significant reductions in perinatal mortality (27.6% vs 59.2%; aOR, 0.24; 95% CI, 0.11-0.5), neonatal intensive care unit admission (75.9% vs 97.6%; aOR, 0.07; 95% CI, 0.01-0.66), and composite adverse neonatal outcome (33.9% vs 90.5%; aOR, 0.05; 95% CI, 0.01-0.21).

CONCLUSION

Cerclage, indomethacin, and antibiotics in twin pregnancies with dilated cervix ≥1 cm before 24 weeks were associated with significant longer latency period from diagnosis to delivery (6.7 weeks), decreased incidence of spontaneous preterm birth at any given gestational age, and improved perinatal outcome when compared with expectant management.

Good prognosis of cerclage in cases of cervical insufficiency when intra-amniotic inflammation/infection is ruled out

OBJECTIVE

To determine if absence of sub-clinical intra-amniotic inflammation improves the prognosis of rescue cerclage in cases of bulging membranes.

METHODS

Cohort study with all women with bulging membranes admitted into our hospital between 2009 and 2013. Patients underwent amniocentesis to quantify amniotic glucose, leukocytes, IL-6 and leukocyte esterase levels and for microbiological culture. All patients without intra-amniotic inflammation or sub-clinical chorioamnionitis were proposed a physical examination-indicated cervical cerclage. Those who did not accept were treated with bed rest.

RESULTS

We enrolled 31 women. Median gestational age at diagnosis was 23 + 1 (21–25 + 4) weeks. Median interval until delivery was 12 (3–52.5) d. IL-6 had the highest diagnostic accuracy for good prognosis. Patients with IL6 <2.90 ng/ml were diagnosed later in pregnancy and presented a longer interval until delivery (89 versus 4 d), higher gestational age at delivery (35 + 1 versus 23 + 3 weeks) and a lower rate of prematurity (54.5% versus 100%) and perinatal mortality (0% versus 80%) than those with IL-6 ≥2.90 ng/ml. Rescue cerclage and low Il-6 were the best predictors of good outcome.

CONCLUSION

IL-6 levels in amniotic fluid may be of clinical value for individualizing the management of patients with bulging membranes for placement of rescue cerclage.

Comparison of two cervical cerclages for the prevention of preterm birth and neonatal complications

OBJECTIVE

To investigate the outcomes of singleton pregnant women with cervical insufficiency undergoing two different cervical cerclages.

METHODS

This is a retrospective cohort study of women who underwent a history- or ultrasound-indicated cerclage (either Shirodkar or McDonald) at a tertiary referral center from 2002 to 2014. Outcome parameters (delivery age, postoperative cervical length, preterm premature rupture of membranes, preterm delivery rate and neonatal complications) were compared between the two cerclage procedures. Multivariate logistic regression analysis was applied to control for significant variables of preterm birth. Kaplan-Meier survival analysis was used to demonstrate delivery age to percentage of term delivery by cerclage type.

RESULTS

Ninety-four cases were initially included. After excluding cases not meeting the study criteria, 60 pregnancies (Shirodkar 36 and McDonald 24) were recruited for analysis. The mean delivery age in the Shirodkar group was more advanced than that in the McDonald group (37.1 ± 3.3 versus 34.8 ± 4.9 weeks, p = 0.039). There were significantly fewer deliveries <37 gestational weeks in the Shirodkar group than in the McDonald group (30.6% versus 58.3%, p = 0.033) but no significant differences in deliveries <28, 32 and 34 gestational weeks. No significant differences were found in neonatal complications except for respiratory distress syndrome (5.6% in Shirodkar versus 29.2% in McDonald, p = 0.023).

CONCLUSION

In the setting of history-indicated or ultrasound-indicated cerclage, Shirodkar was superior to McDonald in the prevention of late preterm birth and neonatal respiratory distress syndrome.

Predictors of Outcomes of Non-Elective Cervical Cerclages

BACKGROUND

Non-elective cervical cerclages are associated with significant perinatal complications. There is scant available information about what the predictors of these outcomes are, thus making counselling difficult.

OBJECTIVE

To identify which factors predict delivery at or beyond 28, 34, and 37 weeks' gestation in women with emergency/rescue cervical cerclage.

METHODS

We conducted a retrospective cohort study of nonelective cerclages over 10 years in our centre. We included women with singleton pregnancies, morphologically normal fetuses, and a cervix dilated to at least 1 cm. Our primary outcome was delivery at or beyond 28 weeks' gestation, and secondary outcomes consisted of delivery at or beyond 34 and 37 weeks' gestation. Descriptive statistical and logistic regression analyses were performed.

RESULTS

We identified a total of 69 cases, and 47 met the inclusion criteria; 44.6% of these women delivered at or beyond 28 weeks' gestation. Membranes seen in the vagina on ultrasound and postcerclage preterm premature rupture of membranes decreased the chance of delivery at or beyond 28 weeks by 81.7% (OR 0.183; 95% CI 0.048 to 0.703) and 95% (OR 0.050; 95% CI 0.006 to 0.429), respectively. The same factors were predictive of deliveries at or beyond 34 and 37 weeks' gestation.

CONCLUSION

Membranes seen in the vagina on ultrasound and postcerclage pre-labour premature rupture of membranes were the strongest predictors of failure to reach 28 weeks' gestation. This information is of critical importance when counselling patients about non-elective cervical cerclage.

Amniocentesis: A contemporary review

Amniocentesis is an essential tool in obstetrics. Invasive testing remains the only modality for diagnostic genetic testing and the only way to provide comprehensive testing for chromosomal abnormalities. Despite increasing use of cell free fetal deoxyribonucleic acid (DNA) testing, amniocentesis should still be offered to all women who desire more complete and accurate genetic testing. Counseling patients on the limitations of screening tests is of the upmost importance and amniocentesis should continue to be recommended to confirm positive results from cell free fetal DNA testing or in the case of failed cell free fetal DNA test. As cell free fetal DNA screening has not adequately been studied in multiple gestations, its use is not recommended in this population and invasive testing should be offered. Amniocentesis is also very useful in providing additional information in settings other than genetic testing the second and third trimester. If intraamniotic infection is suspected, but the clinical findings are not enough to guide management, amniocentesis can provide testing that can both immediately clarify the picture (interleukin-6, gram stain, glucose levels) and finally confirm the presence of infection (culture). It can also be used to detect the presence of intrauterine viral infections. Additionally, amniocentesis may be used to test for markers of fetal lung maturity. The American Congress of Obstetricians and Gynecologists recommends that amniocentesis for this indication not be used in cases where late preterm delivery is indicated. It may be useful in guiding decision-making, however, when late preterm delivery is indicated, but when exact timing is unclear. Regardless of the indication, amniocentesis appears to be a relatively low risk procedure with minimal risk to the patient. Additional randomized controlled trials are not likely, as they are not feasible to due extremely high number of participants that would be needed to detect a difference in loss rates. Based on current literature, however, the risk of pregnancy loss from second trimester amniocentesis is low in both singleton and twin gestations. We counsel patients that technique has changed since the original studies in the 1970s and feel comfortable quoting a loss rate of 1/500-1/1000 based on contemporary data.

Reinforcing cerclage for a short cervix at follow-up after the primary cerclage procedure

OBJECTIVE

To determine whether a reinforcing cerclage (RC) for a short cervix measured after the primary cerclage procedure prolonged pregnancy.

METHODS

We conducted a retrospective cohort study of 157 women with singleton gestations who underwent cerclage for standard indications. Women were grouped according to cervical length (CL) at the time of follow-up 1-2 weeks after the initial cerclage placement: ≥25 mm (106 women) and <25 mm with (20 women) or without RC (31 women). Gestational age (GA) at delivery was compared by ANOVA. Survival risk analysis was applied to model GA at delivery adjusted for indication and CL before and after the first cerclage.

RESULTS

Women with CL ≥25mm delivered later than women with CL < 25mm after the first cerclage (p < 0.01). RC did not delay delivery for women with CL < 25 mm (p = 0.17) after the primary procedure. Indication for the primary cerclage (p < 0.01) and CL (p < 0.01) after the primary cerclage were the best predictors for GA at delivery.

CONCLUSION

Placement of RC for short cervix did not prolong duration of pregnancy, GA at delivery or modify the probability of preterm birth.

Tocolytics used as adjunctive therapy at the time of cerclage placement: a systematic review

OBJECTIVE

To review the published literature on whether the use of empiric perioperative tocolytic medications could provide additional benefit when used in combination with cerclage.

STUDY DESIGN

Systematic review of published medical literature reporting the efficacy of empiric tocolytics used as a perioperative adjunct to vaginal cerclage in high-risk patients. A PubMed search without date criteria of various tocolytics and cerclage yielded 42 studies. Review articles were excluded, as were reports of abdominal cerclage, emergent cerclage, or cerclage for the purpose of delayed interval delivery in twin gestations.

RESULT

Only five publications on the topic of perioperative tocolytic use at the time of history or ultrasound-indicated vaginal cerclage placement were identified. These included zero clinical trials, three retrospective cohort studies, one case series and one case report. Only one cohort study compared cerclage with indomethacin and cerclage without indomethacin and suggested no difference between the groups. The other two published cohort studies had no referent group who received cerclage without tocolysis. One case series and one case report were also published reporting cerclage with empiric beta-mimetic and progesterone adjunctive therapy.

CONCLUSION

There is a paucity of published data on the topic of adjunctive perioperative tocolytics with cerclage. Adequately powered clinical trials on perioperative use of tocolysis with cerclage compared with a standard cerclage placement alone are needed to establish efficacy. Until adequately studied, this practice should be considered investigational.

[Cervical cerclage]

Cervical cerclage aims to strengthen not only the mechanical properties of the cervix, but also its immunological and anti-infectious functions. The demonstration of a strong interrelation between cervical insufficiency as well as decreased cervical length at endo-vaginal ultrasonography and infection has changed the indications cerclage. Actually we can distinguish three indications for cerclage: prophylactic, for obstetrical history; therapeutic, for shortened cervical length at ultrasonography in patients at risk and; emergency cerclage in case of threatening cervix at physical examination. The McDonald's technique is the most recommended. In case of failure, it is proposed to realize cerclage at a higher level on the cervix either by vaginal or abdominal route.

Perinatal outcomes in singleton and twin ICSI pregnancies following hysteroscopic correction of partial intrauterine septa

PURPOSE

To investigate the perinatal outcomes of patients with clinical pregnancies from ICSI treatments who had previously undergone hysteroscopic surgery to correct partial intrauterine septa and compare them to outcomes of patients with no intrauterine anomalies.

METHOD

A retrospective observational analysis of 2024 ultrasound confirmed pregnancies from ICSI treatments performed between January 2005 and June 2012. The patients were grouped according to their intrauterine status, and sub-grouped according to the number of fetal hearts observed; singleton control (n=1128), twin control (n=566), singleton septum (n=217) and twin septum (n=113). The primary outcomes analyzed were miscarriage, preterm, very preterm, stillbirth, vanishing twin and live delivery rates, as well as low birth weight and very low birth weight rates.

RESULT(S)

The live birth rate (89,9 %) in the singleton control subgroup was non-significantly higher than the live birth rate (85,3 %) in the septum subgroup, with a RR of 1,05 (p=0,0583, 95 % CI 0,9943-1,1182) for live birth. In contrast the live birth rate (91,3 %) in twin control subgroup was significantly higher than the live birth rate (84,1 %) in the septum subgroup, with a RR 1,09 (p=0,0282, 95 % CI 0,9988-1,1819). Non-significantly, higher miscarriage and stillbirth rates were the main contributors to the reduced live birth rates. The singleton and twin septum subgroups also had higher rates of premature and very premature delivery and LBWs and vLBW, especially in the singleton septum subgroup.

CONCLUSION(S)

The hysteroscopic correction of intrauterine septa may not eliminate all risks for premature delivery.