MAVRIC: a multicenter randomized controlled trial of transabdominal vs transvaginal cervical cerclage

Cervical cerclage: An evolving evidence base

Cervical cerclage is an established intervention for the management of pregnancies at high risk of preterm birth. Although studies exist to support its use in certain situations, particularly in singleton pregnancies, many questions such as adjunct therapies and efficacy in specific subgroups of high-risk women have not been fully elucidated. This review will assess the current evidence as well as areas where there is currently a paucity of data and an urgent requirement for further research.

Exploring the Limits of Artificial Intelligence for Referencing Scientific Articles

OBJECTIVE

 To evaluate the reliability of three artificial intelligence (AI) chatbots (ChatGPT, Google Bard, and Chatsonic) in generating accurate references from existing obstetric literature.

STUDY DESIGN

 Between mid-March and late April 2023, ChatGPT, Google Bard, and Chatsonic were prompted to provide references for specific obstetrical randomized controlled trials (RCTs) published in 2020. RCTs were considered for inclusion if they were mentioned in a previous article that primarily evaluated RCTs published by the top medical and obstetrics and gynecology journals with the highest impact factors in 2020 as well as RCTs published in a new journal focused on publishing obstetric RCTs. The selection of the three AI models was based on their popularity, performance in natural language processing, and public availability. Data collection involved prompting the AI chatbots to provide references according to a standardized protocol. The primary evaluation metric was the accuracy of each AI model in correctly citing references, including authors, publication title, journal name, and digital object identifier (DOI). Statistical analysis was performed using a permutation test to compare the performance of the AI models.

RESULTS

 Among the 44 RCTs analyzed, Google Bard demonstrated the highest accuracy, correctly citing 13.6% of the requested RCTs, whereas ChatGPT and Chatsonic exhibited lower accuracy rates of 2.4 and 0%, respectively. Google Bard often substantially outperformed Chatsonic and ChatGPT in correctly citing the studied reference components. The majority of references from all AI models studied were noted to provide DOIs for unrelated studies or DOIs that do not exist.

CONCLUSION

 To ensure the reliability of scientific information being disseminated, authors must exercise caution when utilizing AI for scientific writing and literature search. However, despite their limitations, collaborative partnerships between AI systems and researchers have the potential to drive synergistic advancements, leading to improved patient care and outcomes.

KEY POINTS

· AI chatbots often cite scientific articles incorrectly.. · AI chatbots can create false references.. · Responsible AI use in research is vital..

Use of uterine electromyography in the prediction of preterm birth after transvaginal cervical cerclage

BACKGROUND

Preterm birth (PTB), complications of which account for approximately 35% of deaths among neonates, remains a crucial issue. Cervical insufficiency (CI) is defined as the inability of the utrine cervix to retain a pregnancy, leading to PTB. Cervical cerclage is an efficient surgery for CI patients by preventing the cervix from being further mechanically shortened. Unfortunately, a certain number of patients who had cerclage still delivered prematurely, raising the urgent need to accurately assess the risk of PTB in patients with cerclage. Uterine electromyography (uEMG) is an emerging technology that characterizes uterine contractions by describing the actual evolution process of uterine activity and has been used to predict PTB in recent years.

METHOD

In this single-center retrospective case-control study, singleton pregnancy women who received cervical cerclage and uEMG assessment between January 2018 and January 2022 at the Sun Yat-sen Memorial Hospital of Sun Yat-sen University were enrolled.

RESULTS

32 PTBs were observed of the 69 women who underwent assessment. Based on multivariate logistic regression analysis, PTB after cerclage was significantly associated with previous PTB history or mid-trimester pregnancy loss (OR: 2.87, 95%CI: 1.49-5.54) and contraction frequency detected by uEMG (OR: 2.24, 95%CI: 1.44-3.49). The AUC of contraction frequency (0.766, P<0.001) was observed, and the optimal cut-off value suggested by Youden Index was 1.75 times per hour. Combined with previous preterm history and cervical length, the AUC of contraction frequency reached 0.858. After stratification by contraction frequency, the median duration was 11 weeks in the high frequency group (> 1.75 times per hour) and 15 weeks in the low frequency group (≤ 1.75 times per hour) (P<0.001).

CONCLUSIONS

The uEMG effectively predicts PTB after transvaginal cervical cerclage and provides a new method for clinicians to evaluate the pregnancy outcome of CI patients.

Obstetric outcomes of transabdominal cerclage: A retrospective observational study in Japan

OBJECTIVE

This study aimed to investigate the obstetric outcomes of transabdominal cerclage (TAC) in Japan.

METHODS

Questionnaires on TAC were sent to 183 institutions performing high-quality perinatal management in Japan. As a first-step questionnaire, we asked whether TAC was performed between January 1, 2011, and December 31, 2022. In the second step of the questionnaire, the characteristics of all cases were asked from all institutions in which TAC was performed.

RESULTS

The response rate for the first survey was 59% (108/183). Of the 108 institutions, 27 performed TAC (25%) in 133 pregnancies. Of these 27 institutions, 19 responded to the second survey. One hundred twenty-five pregnancies were included in this study, five of which were aborted (gestational weeks <22 weeks), and 69 babies were born after 37 gestational weeks (55%). Eighty-two open abdominal cerclages were performed at 17 institutions and 43 laparoscopic TACs at three institutions. There were no differences in the age at TAC, gestational weeks at TAC, operative time of TAC, gestational weeks at delivery, incidence rate of second-trimester loss, or preterm delivery (before 37 gestational weeks) rate between the two groups. However, blood loss during open TAC was greater than that during laparoscopic TAC.

CONCLUSION

TAC is a rare surgery for cervical insufficiency in Japan. TAC may be a safe and useful method for preventing second-trimester loss and preterm delivery in high-risk patients. TAC may also be a key option in Japan to improve perinatal outcomes in patients with cervical insufficiency.

Socioeconomic and ethnic disparities in preterm births in an English maternity setting: a population-based study of 1.3 million births

BACKGROUND

Preterm birth is a major cause of infant mortality and morbidity and accounts for 7-8% of births in the UK. It is more common in women from socially deprived areas and from minority ethnic groups, but the reasons for this disparity are poorly understood. To inform interventions to improve child survival and their quality of life, this study examined the socioeconomic and ethnic inequalities in preterm births (< 37 weeks of gestation at birth) within Health Trusts in England.

METHODS

This study investigated socioeconomic and ethnic inequalities in preterm birth rates across the National Health Service (NHS) in England. The NHS in England can be split into different units known as Trusts. We visualised between-Trust differences in preterm birth rates. Health Trusts were classified into five groups based on their standard deviation (SD) variation from the average national preterm birth rate. We used modified Poisson regression to compute risk ratios (RR) and 95% confidence intervals (95% CI) with generalised estimating equations.

RESULTS

The preterm birth rate ranged from 6.8/100 births for women living in the least deprived areas to 8.8/100 births for those living in the most deprived areas. Similarly, the preterm birth rate ranged from 7.8/100 births for white women, up to 8.6/100 births for black women. Some Health Trusts had lower than average preterm birth rates in white women whilst concurrently having higher than average preterm birth rates in black and Asian women. The risk of preterm birth was higher for women living in the most deprived areas and ethnicity (Asian).

CONCLUSIONS

There was evidence of variation in rates of preterm birth by ethnic group, with some Trusts reporting below average rates in white ethnic groups whilst concurrently reporting well above average rates for women from Asian or black ethnic groups. The risk of preterm birth varied substantially at the intersectionality of maternal ethnicity and the level of socioeconomic deprivation of their residency. In the absence of other explanations, these findings suggest that even within the same Health Trust, maternity care may vary depending on the women's ethnicity and/or whether she lives in an area of high socioeconomic deprivation. Thus, social factors are likely key determinants of inequality in preterm birth rather than provision of maternity care alone.

Comparison of maternal and neonatal morbidity in transvaginal versus transabdominal cerclage patients: A retrospective study from two tertiary hospitals

OBJECTIVE

To compare the maternal and neonatal morbidity in patients with transvaginal (TVC) versus transabdominal (TAC) cerclage.

MATERIALS AND METHODS

Retrospective analysis of patients who received cervical cerclage and terminated the pregnancy in the second trimester or third trimester in two tertiary hospitals. Data on basic clinical characteristics, predelivery maternal morbidity, intrapartum morbidity, postpartum morbidity and neonatal morbidity of TVC patients and TAC patients were analysed and compared.

RESULTS

Seventy-two TVC patients and 120 TAC patients were included. The rates of abnormal fetal presentation and placental disorders were significantly higher in TAC patients than that in TVC patients (21.67% vs 5.56% and 18.33% vs 4.17%, respectively). The rates of premature rupture of membranes and intrauterine infection were significantly higher in TVC patients than that in TAC patients (25.00% vs 2.50% and 11.23% vs 3.33%, respectively). Compared with TVC patients, the rates of estimated intrapartum hemorrhage ≥500 ml, uterine rupture and cesarean delivery in the third trimester were significantly higher in TAC patients than in TVC patients. Gestational age at delivery and neonatal morbidity were comparable between TVC patients and TAC patients.

CONCLUSION

Compared with TVC patients, TAC patients were associated with a significantly higher incidence of maternal morbidity in placental disorders, abnormal fetal presentation, intrapartum hemorrhage ≥500 ml and uterine rupture.

First birth after uterine transposition in low-volume lymph node metastasis of cervical cancer: A long journey for success

Locally advanced cervical cancer poses a significant challenge to fertility-sparing treatments. Pelvic radiotherapy impairs reproductive potential owing to ovarian, uterine, and endometrial side effects. This study presents a literature review of the main fertility-sparing therapeutic alternatives for locally advanced cervical cancer and a case report of the first childbirth following uterine transposition for gynecological malignancies.

Comparison between vaginal and laparoscopic cerclage in women with mid-trimester pregnancy loss or history of spontaneous preterm delivery

BACKGROUND

Women with unfavorable obstetric history can benefit from prophylactic cerclage ("history indicated") which can be performed vaginally or transabdominally with laparoscopic techniques. The aim of our study is to evaluate the effectiveness in the prevention of preterm birth of the vaginal technique and of the minimally invasive laparoscopic technique in women with an unfavorable obstetric history.

METHODS

This was a retrospective cohort study examining elective cerclages performed in women with adverse obstetrics history. The primary outcome was rate of early preterm and second trimester deliveries while other outcomes analyzed were surgical complications, the time needed for cerclage procedures, live birth rate, gestational age at delivery, birth weight, Apgar score.

RESULTS

Data from 64 women were analyzed; among them, 14 underwent a laparoscopic procedure (22%) while 50 a vaginal cerclage (78%). The two groups were homogeneous in terms of demographic characteristics, but of course differed significantly in terms of obstetrics history, as well as for the surgical indications of cerclage procedures. The rate of early preterm deliveries and second trimester miscarriage were the same in the vaginal and laparoscopic group (8%), comparable to what was reported in literature. The operative time was longer in the laparoscopic group, but with similar duration of the hospital stay. We reported no intraoperative complications in both groups.

CONCLUSIONS

As the laparoscopic procedure, usually reserved for women with a previous failed vaginal cerclage, has been proved to be equally safe and effective, it may could be proposed to a wider group of women. Prospective randomized studies are needed to provide new and conclusive data about this topic.

Preterm birth in low-middle income Countries

Preterm birth (PTB), remains a major cause of significant morbidity and mortality world-wide with about 12-15million preterm births occurring every year. Although the overall trend is decreasing, this is mainly in high-income countries (HIC). The rate remains high in low-and middle-income countries (LMIC) varying on average between 10 and 12% compared to 9% in HIC. The pathogenesis of PTB is complex and multifactorial. Attempts to reduce rates that have focused on PTB as a single condition have in general been unsuccessful. However, more recent attempts to phenotype PTB have resulted in targeted preventative approaches which are yielding better results. Prevention (primary or secondary) is the only approach that has been shown to make a difference to rates of PTB. These include identifying risk factors pre-pregnancy and during pregnancy and instituting appropriate measures to address these. In LMIC, although some approaches that have been shown to be effective in some HIC are adaptable, there is a need to involve stakeholders at all levels in utilizing evidence preferrably generated in LMIC to implement strategies that are likely to reduce the rate of PTB. In this review, we focus on prevention and how to involve policy makers in the process of applying evidence into policy that would reduce PTB in LMIC.

Laparoscopic prepregnancy transabdominal cerclage: operative and pregnancy outcomes for a novel technique of suture placement using port closure device

Transabdominal cerclage is an effective surgical intervention for preterm birth prevention. Placement of cervical sutures using a port closure device for prepregnancy laparoscopic abdominal cerclage has been used at our unit in recent years. We report the operative and pregnancy outcomes for prepregnancy laparoscopic abdominal cerclage using the port closure device and compare it with the outcomes of the traditional approach. For prepregnancy laparoscopic transabdominal cerclage (n=52), the port closure device approach was associated with less blood loss during surgery (0.95±4.4 mL vs 5.4±15.7 mL; P=.007) and a shorter hospital length of stay (0.0; 0.0-0.0 days vs 1.0; 0.0-1.0 days; P<.001). There were also trends toward shorter operating times (41.4±15.3 minutes vs 50.1±18.0 minutes; P=.167) and lower perioperative complication rates (0.0%; 0/21 vs 16.1%; 5/31; P=.065) when compared with the traditional technique. There was no significant difference between the port closure device technique and the traditional approach in the rate of preterm birth in a subsequent pregnancy (0.0%; 0/9 vs 22.6%; 7/39; P=.248). Use of the port closure device for suture placement during prepregnancy laparoscopic cerclage for preterm birth prevention was reported. This technique was associated with less blood loss and a shorter hospital length of stay, had trends toward shorter operating times and lower perioperative complication rates, and had similar rates of preterm birth.

Cerclage prevents ascending intrauterine infection in pregnant mice

BACKGROUND

The treatment for cervical insufficiency is cerclage surgery. Although cerclage is a common therapy for prevention of preterm birth, there is no consensus about its mechanism of efficacy. Previous investigators have hypothesized that cerclage prevents preterm birth by improving the cervical barrier to ascending infection. However, this hypothesis is difficult to study in human pregnancy.

OBJECTIVE

In a mouse model of ascending infection, we hypothesized that a cerclage improves the cervical barrier leading to decreased ascending intrauterine infection and inflammation. An abdominal cerclage was studied because a vaginal cerclage is not feasible in mice.

STUDY DESIGN

To perform an abdominal cerclage, laparotomy was performed on timed, pregnant C57BL/6 mice on gestational day 10 (E10). A 6-0 silk suture was placed around the cervix just below the junction of the 2 uterine horns. Sham controls received the same surgery, but no cerclage was placed. To track ascending infection nonpathogenic E coli K12 was genetically modified to express bioluminescence. On E15, bioluminescent E coli K12 (20 μL of 1×109 bacteria) was inoculated into the vagina. Whole-body bioluminescence imaging was performed 0.5 hours and 24 hours after inoculation. To assess intrauterine inflammation, pathogenic E coli K1 was used. On E15, bacterial inoculums of E coli K1 (20 μL of 1×104 bacteria) were vaginally administered. Samples of uterus, placenta, and fetal membranes were collected 24 hours after inoculation. Gene expression of inflammation-related proteins was compared between 3 groups: (1) sham control surgery + inoculation of phosphate-buffered saline (PBS), (2) sham control surgery + inoculation of E coli K1, and (3) cerclage surgery + inoculation of E coli K1.

RESULTS

Abdominal cerclage was well tolerated. No cases of preterm birth were seen following abdominal cerclage. Whole-body bioluminescent imaging performed 0.5 hours post inoculation showed a strong luminescence signal in the vaginal region of mice in both control and experimental groups indicating successful bacteria inoculation. Twenty-four hours after inoculation, bioluminescent signal was seen ascending into the uterine horns in all control mice. However, in mice with abdominal cerclages, no bioluminescent signal was seen after 24 hours. When the reproductive tissues were imaged separately in control mice, strong bioluminescence signal was detected in the placenta, fetal membranes, and uterus. Gene expression studies showed that cerclage significantly decreased the expression of inflammatory proteins induced by E coli K1 in the uterus, placenta, and fetal membranes.

CONCLUSION

In this mouse model of ascending intrauterine infection, abdominal cerclage prevented ascending infection of E coli. In addition, abdominal cerclage prevented expression of inflammatory cytokines in the uterus, placenta, and membranes of mice. The study provides evidence for a potential mechanism of cerclage success in human pregnancy.

Development and validation of models for predicting preterm birth and gestational latency following emergency cervical cerclage: A multicenter cohort study

INTRODUCTION

Emergency cervical cerclage is a recognized method for preventing mid-trimester pregnancy loss and premature birth; however, its benefits remain controversial. This study aimed to establish preoperative models predicting preterm birth and gestational latency following emergency cervical cerclage in singleton pregnant patients with a high risk of preterm birth.

MATERIAL AND METHODS

We retrospectively reviewed data from patients who received emergency cerclage between 2015 and 2023 in three institutions. Patients were grouped into a derivation cohort (n = 141) and an independent validation cohort (n = 61). Univariate and multivariate logistic and Cox regression analyses were used to identify independent predictive variables and establish the models. Harrell's C-index, time-dependent receiver operating characteristic curves and areas under the curves, calibration curve, and decision curve analyses were performed to assess the models.

RESULTS

The models incorporated gestational weeks at cerclage placement, history of prior second-trimester loss and/or preterm birth, cervical dilation, and preoperative C-reactive protein level. The C-index of the model for predicting preterm birth before 28 weeks was 0.87 (95% CI: 0.82-0.93) in the derivation cohort and 0.82 (95% CI: 0.71-0.92) in the independent validation cohort; The C-index of the model for predicting gestational latency was 0.70 (95% CI: 0.66-0.75) and 0.78 (95% CI: 0.71-0.84), respectively. In the derivation set, the areas under the curves were 0.84, 0.81, and 0.84 for predicting 1-, 3- and 5-week pregnancy prolongation, respectively. The corresponding values for the external validation were 0.78, 0.78, and 0.79, respectively. Calibration curves showed a good homogeneity between the observed and predicted ongoing pregnant probabilities. Decision curve analyses revealed satisfactory clinical usefulness.

CONCLUSIONS

These novel models provide reliable and valuable prognostic predictions for patients undergoing emergency cerclage. The models can assist clinicians and patients in making personalized clinical decisions before opting for the cervical cerclage.

Urogenital cultures and preterm birth in women with cervical cerclage: a single center retrospective cohort study

BACKGROUND

The leading hypothesis of the pathogenesis of cervical insufficiency suggests a role of cervical inflammation. Urogenital tract infections could play a causative role in this process. To test this hypothesis in women with a cervical cerclage, we aimed to retrospectively examine the relationship between gestational age (GA) at delivery and positive urogenital cultures.

METHODS

This single center retrospective study reviewed the records of all women with a singleton pregnancy that underwent cervical cerclage (n = 203) between 2010 and 2020 at the University Hospital of Leuven, Belgium. Transvaginal cerclages were categorized as history indicated (TVC I, n = 94), ultrasound indicated (TVC II, n = 79) and clinically indicated (TVC III, n = 20). Additionally, ten women received transabdominal cerclage (TAC). Urogenital cultures (vaginal and urine) were taken before and after cerclage with 4-week intervals. Urogenital cultures were reported 'positive' if urine and/or vaginal cultures showed significant growth of a microorganism. Treatment decision depended on culture growth and clinical presentation. The primary aim was to evaluate the association between the urogenital culture results and the GA at delivery, for each of the cerclage groups. Secondarily, to investigate the effect of antibiotic treatment of positive cultures on GA at delivery.

RESULTS

Positive pre-cerclage urogenital cultures were associated with lower GA at delivery in TVC III (positive culture 26w4d ± 40d vs. negative 29w6d ± 54d, p = 0.036). For TVC I, GA at delivery was longer when pre-cerclage urogenital cultures were positive (positive culture 38w0d ± 26d vs. negative 35w4d ± 42d, p = 0.035). Overall post-cerclage urogenital cultures status was not associated with a different GA at delivery. Treating patients with pre- or post-cerclage positive urogenital cultures did also not change GA at delivery.

CONCLUSION

Positive urogenital cultures taken before clinically indicated cerclage intervention may be associated with lower GA at delivery. However, there seems to be no benefit of antibiotic treatment or routine urogenital cultures during follow-up of asymptomatic women after cerclage placement.

Effect of different surgical routes on pregnancy outcome of history-indicated cervical cerclage

OBJECTIVE

To study the guiding significance of medical history on laparoscopic and vaginal cervical cerclage in the treatment of cervical incompetence and its influence on pregnancy outcome.

METHODS

A total of 53 cases by laparoscopic abdominal cervical cerclage (LAC group) before pregnancy and 73 cases by transvaginal cervix cerclage (TVC group) at 12-14 weeks of pregnancy were collected. Multivariate logistic regression analysis was performed on the influencing factors of delivery gestational weeks. Furthermore, the gestational weeks after cervical cerclage were compared between the two groups with high- and low-risk grades.

RESULTS

The number of previous uterine cavity operations in LAC group was more than that TVC group, and the costs of operation were more than TVC group. At the same time, the hospitalization days and operation time were longer than those in TVC group, and the delivery rate of cesarean section was higher than TVC group, but the total hospitalization times were less than TVC group (P < 0.05). The rate of delivery before 34 weeks of pregnancy and the incidence of premature rupture of membranes or premature labor in LAC group were lower than those in TVC group (P < 0.05). In TVC group, the increased number of prior PTB or STL and the history of cervical cerclage failure would increase the risk of premature delivery before 34 weeks of pregnancy. There was no increased risk of preterm delivery before 34 weeks of pregnancy in LAC group (P > 0.05). According to the risk level, in the high-risk group, the delivery rate of LAC group at gestational weeks < 37 weeks, < 34 weeks and < 28 weeks was lower than that of TVC group.

CONCLUSION

Laparoscopic cervical cerclage might be more effective in preventing premature delivery before 34 weeks of gestation, and its influence on delivery gestational weeks was not affected by related medical history. For high-risk patients with the history of prior PTB or STL and failed cerclage, laparoscopic cervical cerclage might be more effective than vaginal cervical cerclage in preventing extremely preterm before 28 weeks, premature delivery before 34 weeks and premature delivery before 37 weeks. Therefore, our limited experience suggested that LAC can be a recommended option for patients with high-risk history.

Strategies for Safeguarding High-Risk Pregnancies From Preterm Birth: A Narrative Review

Preterm birth is the delivery of a live fetus before the 37th week of gestation. Preterm birth may stem from various factors, including premature rupture of membranes, spontaneous preterm labor, or medically induced circumstances. Premature delivery can result in serious and long-lasting difficulties even for infants who survive, as it is the leading cause of death for infants under five years old. Numerous nations have implemented initiatives to detect and track pregnant women who may give birth before their due date. Numerous therapies are available to protect these at-risk groups from the devastating effects of premature delivery, given the complex nature of preterm birth risk factors. Among the preventive measures, prophylactic progesterone appears to hold significant promise, while cervical cerclage proves effective in cases of cervical insufficiency. Conversely, pessaries show no discernible beneficial effects in reducing the risk of preterm birth. Regular antenatal visits are imperative for frequent patient evaluation and screening for potential risk factors. Adopting a healthy lifestyle can influence the risk of developing preeclampsia, with regular physical activity, a fiber-rich diet, and smoking cessation serving to mitigate the risk of preterm birth. The efficacy of bed rest in preventing preterm birth remains inconclusive due to insufficient evidence. This study aims to explore various preventive strategies for averting premature birth in high-risk women.

A Retrospective Study Comparing Laparoscopic Transabdominal Cerclage: Pre-Pregnancy Versus in Pregnancy With Their Reproductive Outcomes and Safety

OBJECTIVES

To compare the efficacy of laparoscopic transabdominal cerclage (TAC) pre-pregnancy and laparoscopic TAC in pregnancy in treating cervical insufficiency.

METHOD

A retrospective analytical study comparing outcomes of laparoscopic TAC pre-pregnancy with laparoscopic TAC in pregnancy. A total of 178 patients who underwent laparoscopic TAC at our hospital were enrolled in the study. In total, 122 patients underwent interval cerclage, and 56 patients underwent cerclage during pregnancy.

RESULTS

A total of 178 patients who met the inclusion criteria were included in the analysis. Second-trimester abortions decreased by 50%, with an overall increase in full-term live births (32.53%) in patients undergoing laparoscopic TAC pre-pregnancy. The fetal survival rate was around 90% and 85% with laparoscopic TAC pre-pregnancy and laparoscopic TAC in pregnancy, respectively. Although the obstetric outcomes of laparoscopic TAC pre-pregnancy and in pregnancy were comparable, laparoscopic TAC pre-pregnancy was safer than laparoscopic TAC in pregnancy due to the complications associated with the procedure during pregnancy.

CONCLUSIONS

Laparoscopic TAC pre-pregnancy yielded better reproductive outcomes than laparoscopic TAC in pregnancy and was associated with fewer perioperative complications.

Hyposecretion of cervical MUC5B is related to preterm birth in pregnant women after cervical excisional surgery

PROBLEM

Excisional surgery for cervical intraepithelial neoplasia is a risk factor for preterm birth in subsequent pregnancies. However, the underlying mechanisms of this association remain unclear. We previously showed that cervical MUC5B, a mucin protein, may be a barrier to ascending pathogens during pregnancy. We thus hypothesized that hyposecretion of cervical MUC5B is associated with preterm birth after cervical excisional surgery.

METHOD OF STUDY

This prospective nested case-control study (Study 1) included pregnant women who had previously undergone cervical excisional surgery across 11 hospitals. We used proteomics to compare cervicovaginal fluid at 18-22 weeks of gestation between the preterm and term birth groups. In another case-control analysis (Study 2), we compared MUC5B expression in nonpregnant uterine tissues between 15 women with a history of cervical excisional surgery and 26 women without a history of cervical surgery.

RESULTS

The abundance of MUC5B in cervicovaginal fluid was significantly decreased in the preterm birth group (fold change = 0.41, p = .035). Among the 480 quantified proteins, MUC5B had the second highest positive correlation with gestational age at delivery in the combined preterm and term groups. The cervicovaginal microbiome composition was not significantly different between the two groups. Cervical length was not correlated with gestational age at delivery (r = 0.18, p = .079). Histologically, the MUC5B-positive area in the nonpregnant cervix was significantly decreased in women with a history of cervical excisional surgery (0.85-fold, p = .048). The distribution of MUC5B-positive areas in the cervical tissues of 26 women without a history of cervical excisional surgery differed across individuals.

CONCLUSIONS

This study suggests that the primary mechanism by which cervical excisional surgery causes preterm birth is the hyposecretion of MUC5B due to loss of the cervical glands.

Favorable surgical and obstetrical outcomes in pre- and postconceptional laparoscopic abdominal cerclage: a large multicenter cohort study

BACKGROUND

Cervical incompetence is an important cause of extremely preterm delivery. Without specialized treatment, cervical incompetence has a 30% chance of recurrence in a subsequent pregnancy. Recently, the first randomized controlled trial showed significant superiority of abdominal cerclage compared with both high and low vaginal cerclage in preventing preterm delivery at <32 weeks of gestation and fetal loss in patients with a previous failed vaginal cerclage.

OBJECTIVE

This study aimed to assess surgical and obstetrical outcomes in patients with pre- and postconceptional laparoscopic abdominal cerclage placement. Furthermore, it also aimed to perform subgroup analysis based on the indication for cerclage placement in order to identify patients who benefit the most from an abdominal cerclage.

STUDY DESIGN

A retrospective multicenter cohort study with consecutive inclusion of all eligible patients from 1997 onward in the Dutch cohort (104 patients) and from 2007 onward in the Boston cohort (169 patients) was conducted. Eligible patients had at least 1 second- or third-trimester fetal loss due to cervical incompetence and/or a short or absent cervix after cervical surgery. This includes loop electrosurgical excision procedure, conization, or trachelectomy. Patients were divided into the following subgroups based on the indication for cerclage placement: (1) previous failed vaginal cerclage, (2) previous cervical surgery, and (3) other indications. The third group consisted of patients with a history of multiple second- or early third-trimester fetal losses due to cervical incompetence (without a failed vaginal cerclage) and/or multiple dilation and curettage procedures. The primary outcome measure was delivery at ≥34 weeks of gestation with neonatal survival at hospital discharge. Secondary outcome measures included surgical and obstetrical outcomes, such as pregnancy rates after preconceptional surgery, obstetrical complications, and fetal survival rates.

RESULTS

A total of 273 patients were included (250 in the preconceptional and 23 in the postconceptional cohort). Surgical outcomes of 273 patients were favorable, with 6 minor complications (2.2%). In the postconceptional cohort, 1 patient (0.4%) had hemorrhage of 650 mL, resulting in conversion to laparotomy. After preconceptional laparoscopic abdominal cerclage (n=250), the pregnancy rate was 74.1% (n=137) with a minimal follow-up of 12 months. Delivery at ³34 weeks of gestation occurred in 90.5% of all ongoing pregnancies. Four patients (3.3%) had a second-trimester fetal loss. The indication for cerclage in all 4 patients was a previous failed vaginal cerclage. The other subgroups showed fetal survival rates of 100% in ongoing pregnancies, with a total fetal survival rate of 96%. After postconceptional placement, 94.1% of all patients with an ongoing pregnancy delivered at ³34 weeks of gestation, with a total fetal survival rate of 100%. Thus, second-trimester fetal losses did not occur in this group.

CONCLUSION

Pre- and postconceptional laparoscopic abdominal cerclage is a safe procedure with favorable obstetrical outcomes in patients with increased risk of cervical incompetence. All subgroups showed high fetal survival rates. Second-trimester fetal loss only occurred in the group of patients with a cerclage placed for the indication of previous failed vaginal cerclage, but was nevertheless rare even in this group.

Prevention of spontaneous preterm delivery – an update on where we are today

Spontaneous preterm birth (delivery before 37 completed weeks) is the single most important cause of perinatal morbidity and mortality. The rate is increasing world-wide with a great disparity between low, middle and high income countries. It has been estimated that the cost of neonatal care for preterm babies is more than 4 times that of a term neonate admitted into the neonatal care. Furthermore, there are high costs associated with long-term morbidity in those who survive the neonatal period. Interventions to stop delivery once preterm labor starts are largely ineffective hence the best approach to reducing the rate and consequences is prevention. This is either primary (reducing or minimizing factors associated with preterm birth prior to and during pregnancy) or secondary - identification and amelioration (if possible) of factors in pregnancy that are associated with preterm labor. In the first category are optimizing maternal weight, promoting healthy nutrition, smoking cessation, birth spacing, avoidance of adolescent pregnancies and screening for and controlling various medical disorders as well as infections prior to pregnancy. Strategies in pregnancy, include early booking for prenatal care, screening and managing medical disorders and their complications, and identifying predisposing factors to preterm labor such as shortening of the cervix and timely instituting progesterone prophylaxis or cervical cerclage where appropriate. The use of biomarkers such as oncofetal fibronectin, placental alpha-macroglobulin-1 and IGFBP-1 where cervical screening is not available or to diagnosis PPROM would identify those that require close monitoring and allow the institution of antibiotics especially where infection is considered a predisposing factor. Irrespective of the approach to prevention, timing the administration of corticosteroids and where necessary tocolysis and magnesium sulfate are associated with an improved outcome. The role of genetics, infections and probiotics and how these emerging dimensions help in the diagnosis of preterm birth and consequently prevention are exciting and hopefully may identify sub-populations for targeted strategies.

"I had given up on being a mother": a survey of 183 women's experience of transabdominal cerclage (TAC)

BACKGROUND

Transabdominal cerclage (TAC) is a relatively uncommon intervention for preventing preterm birth. This study aimed to investigate the experience of women who had undergone this procedure.

METHODS

The survey was designed in collaboration with a preterm birth studies public and patient involvement (PPI) group and ethical approval was granted by KCL BDM Research Ethics Panel (LRS-19/20-13205). Members of closed Facebook group, UK TAC Support, were invited to complete an online questionnaire about their experience of TAC, and pregnancies before and after having it placed. The survey was open between December 2019 and May 2020. Open and closed questions provided both qualitative and quantitative data for analysis, which was carried out using NVivo Pro 2020 v.1.4.1 qualitative data management software and SPSS Statistics 27 (IBM).

RESULTS

One hundred eighty-three participants completed the survey, having had TAC procedures carried out in 36 hospitals. Altogether, participants had experienced 287 preterm births (PTB) and late miscarriages (LM), equating to an average of 1.6 each (range 0-5), including 18 stillbirths. TAC was indicated in 123 (67%) for previous PTB and/or LM, 29 (16%) for cervical surgery and 31 (17%) for both. 151 (83%) TAC procedures were open, 32 (17%) laparoscopic. 86% (n = 157) were placed outside pregnancy. Of those placed in pregnancy, gestation at TAC ranged from 7 to 16 weeks. When comparing earliest pre- and post-TAC pregnancy gestation (excluding first trimester losses), median gestational weeks gained following TAC was 15.5 weeks (SD 6.89). Qualitative themes included: the struggle to get treatment; lack of TAC knowledge amongst clinicians; gratitude, hope and feeling protected; possible detrimental effects of TAC.

CONCLUSIONS

This very high-risk group found having a TAC gave great reassurance and hope, and were very grateful to have found the care they needed. However, they often struggled to get this support, frequently due to lack of clinician awareness. This may improve following roll-out of NHS England's Saving Babies Live Care Bundle and NHS commissioning guidelines for care of women at risk of PTB.

Persistence Pays Off: Live Birth after Uterus Transplant, Overcoming Recurrent Pregnancy Loss with Cerclage Placement

Recipients of uterus transplantation have unique factors that may increase their risk of cervical insufficiency. This report describes a uterus transplant recipient with cervical insufficiency resulting in two second-trimester miscarriages. After McDonald cerclages (one that failed), she underwent an interval transabdominal cerclage and delivered a healthy term child in her third pregnancy. The longitudinal information of this case provides observations from which we can propose testable hypotheses that address venous outflow and inflammation. This case also suggests that there could be a role for prophylactic cerclage placement at the time of transplantation.

The minimally invasive approach to abdominal cerclage: indications, complications, and techniques for placement

PURPOSE OF REVIEW

Laparoscopic abdominal cerclage placement has become the favored approach for management of refractory cervical insufficiency. There are special considerations with respect to surgical method, management of pregnancy loss, and delivery following placement. This review addresses current literature on transabdominal cerclage with a focus on up-to-date minimally invasive techniques.

RECENT FINDINGS

Recent literature on abdominal cerclage has compared laparoscopic and open approaches, evaluated the effect of preconception placement on fertility, and explored the upper gestational limit for dilation and evacuation with an abdominal cerclage in situ .

SUMMARY

The objective of this article is to help minimally invasive surgeons identify candidates for transabdominal cerclage placement, understand surgical risks, succeed in their laparoscopic approach, and appropriately manage patients postoperatively.

Longitudinal change in cervical length following vaginal or abdominal cervical cerclage: a randomized comparison

BACKGROUND

Cervical cerclage has been shown to reduce the risk of recurrent spontaneous preterm birth in a high-risk patient population; however, the mechanism is not well understood. Transabdominal cerclage is superior to low and high vaginal cerclage in reducing early spontaneous preterm birth and fetal loss in women with previous failed vaginal cerclage. Cervical length measurements are commonly used to monitor high-risk women and may explain the mechanism of success.

OBJECTIVE

This study aimed to evaluate the rate of change in longitudinal cervical length after randomized placement of low transvaginal, high transvaginal, or transabdominal cerclage in women with a previous failed vaginal cerclage.

STUDY DESIGN

This was a planned analysis of longitudinal transvaginal ultrasound cervical length measurements from patients enrolled in the Vaginal Randomised Intervention of Cerclage trial, a randomized controlled trial comparing transabdominal cerclage or high transvaginal cerclage with low transvaginal cerclage. Cervical length measurements at specific gestational ages were compared over time and between groups, using generalized estimating equations fitted using the maximum-likelihood random-effects estimator. In addition, cervical length measurements were compared in women with transabdominal cerclage placed before and during pregnancy. The diagnostic accuracy of cervical length as a predictor of spontaneous preterm birth at <32 weeks of gestation was explored.

RESULTS

This study included 78 women who underwent longitudinal cervical length assessment (70% of the analyzed cohort) with a history of failed cerclage, of whom 25 (32%) were randomized to low transvaginal cerclage, 26 (33%) to high transvaginal cerclage, and 27 (35%) to transabdominal cerclage. Abdominal cerclage was superior to low (P=.008) and high (P=.001) vaginal cerclage at maintaining cervical length over the surveillance period (14 to 26 weeks of gestation) (+0.08 mm/week, 95% confidence interval, -0.40 to 0.22; P=.580). On average, the cervical length was 1.8 mm longer by the end of the 12-week surveillance period in women with transabdominal cerclage (+1.8 mm; 95% confidence interval, -7.89 to 4.30; P=.564). High vaginal cerclage was no better than low cervical cerclage in the prevention of cervical shortening; the cervix shortened by 13.2 mm over 12 weeks in those with low vaginal cerclage (95% confidence interval, -21.7 to -4.7; P=.002) and by 20 mm over 12 weeks in those with high vaginal cerclage (95% confidence interval, -33.1 to -7.4; P=.002). Preconception transabdominal cerclage resulted in a longer cervix than those performed during pregnancy; this difference was significant after 22 weeks of gestation (48.5 mm vs 39.6 mm; P=.039). Overall, cervical length was an excellent predictor of spontaneous preterm birth at <32 weeks of gestation (receiver operating characteristic curve, 0.92; 95% confidence interval, 0.82-1.00).

CONCLUSION

In women with a previous failed cervical cerclage, in the next pregnancy, the cervical length in women treated with vaginal cerclage funneled and shortened over time, whereas there was preservation of cervical length in women who receive transabdominal cerclage. Cervical length remained longer in transabdominal procedures performed before pregnancy than in transabdominal procedures performed during pregnancy. Overall, cervical length was an excellent predictor of spontaneous preterm birth in our cohort. Our findings may explain the mechanism of benefit for transabdominal cerclage, with its high placement better maintaining the structural integrity of the cervix at the level of the internal os.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry Number 015/025, September 2022) - Part 1 with Recommendations on the Epidemiology, Etiology, Prediction, Primary and Secondary Prevention of Preterm Birth

Aim This revised guideline was coordinated by the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (OEGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). It aims to improve the prediction, prevention, and management of preterm birth, based on evidence from the current literature, the experience of members of the guidelines commission, and the viewpoint of self-help organizations. Methods The members of the contributing professional societies and organizations developed recommendations and statements based on international literature. The recommendations and statements were presented and adopted using a formal process (structured consensus conferences with neutral moderation, written Delphi vote). Recommendations Part 1 of this short version of the guideline presents statements and recommendations on the epidemiology, etiology, prediction, and primary and secondary prevention of preterm birth.

The impact of cerclage placement on gestational length in women with premature cervical shortening

OBJECTIVES

Cervical insufficiency (CI) is a condition consistent with painless cervical dilatation that can lead to preterm delivery. Cervical cerclage is a procedure in which cervical suture is performed for preventing preterm labor in several indications. Late emergency cerclage is technically more challenging compared to elective cerclage, performed earlier during pregnancy, prior to cervical changes. Pregnancy outcomes with emergency cerclage were found to be improved in previous reports, but there is still inconclusive data. To assess the effectiveness and safety of emergency cerclage vs. conservative management with progesterone and/or bed resting, in preventing preterm birth and improving neonatal outcomes in women with clinically evident cervical insufficiency.

METHODS

This is a retrospective cohort study conducted on all women diagnosed with cervical insufficiency between the 16th and 24th gestational week who met the inclusion criteria, from January 2012 to December 2018. Obstetric and neonatal outcomes: time from diagnosis to delivery, duration of pregnancy, birth weight and Apgar score, were compared between women who underwent cerclage and those who treated conservatively.

RESULTS

Twenty eight women underwent emergency cerclage (cerclage group) and 194 managed with a conservative therapy, progesterone and/or bed rest (control group). Time from diagnosis to delivery 13 weeks vs. 8 weeks and birth weight 2,418 g vs. 1914 g were significantly higher in the first cohort. Average pregnancy duration was three weeks longer in the cerclage group, but that was not significant. No complications occurred in the cerclage group and no difference in mode of delivery were found.

CONCLUSIONS

Emergency cerclage is an effective and safe procedure in preventing preterm birth and prolongation of pregnancy, in women with cervical insufficiency in the late second trimester.

Management of Pregnancy with Cervical Shortening: Real-Life Clinical Challenges

Background and Objectives: Preterm birth is the leading cause of neonatal mortality worldwide and may be responsible for lifelong morbidities in the survivors. Cervical shortening is one of the common pathways to preterm birth associated with its own diagnostic and management challenges. The preventive modalities that have been tested include progesterone supplementation and cervical cerclage and pessaries. The study aimed to assess the management strategies and outcomes in a group of patients with a short cervix during pregnancy or cervical insufficiency. Materials and Methods: Seventy patients from the Riga Maternity Hospital in Riga, Latvia, were included in the prospective longitudinal cohort study between 2017 and 2021. Patients were treated with progesterone, cerclage, and/or pessaries. The signs of intra-amniotic infection/inflammation were assessed, and antibacterial therapy was given when the signs were positive. Results: The rates of PTB were 43.6% (n = 17), 45.5% (n = 5), 61.1% (n = 11), and 50.0% (n = 1) in progesterone only, cerclage, pessary, and cerclage plus pesssary groups, respectively. The progesterone therapy was associated with a reduced preterm birth risk (x2(1) = 6.937, p = 0.008)), whereas positive signs of intra-amniotic infection/inflammation significantly predicted the risk of preterm birth (p = 0.005, OR = 3.82, 95% [CI 1.31–11.11]). Conclusions: A short cervix and bulging membranes, both indicators of intra-amniotic infection/inflammation, are the key risk factors in preterm birth risk predictions. Progesterone supplementation should remain at the forefront of preterm birth prevention. Among patients with a short cervix and especially complex anamnesis, the preterm rates remain high. The successful management of patients with cervical shortening lies between the consensus-based approach for screening, follow-up, and treatment on the one side and personalising medical therapy on the other.

Transabdominal cerclage during pregnancy: A retrospective single operator series over a quarter century

OBJECTIVE

To describe the pregnancy outcomes and complications observed in a series of cases of transabdominal cerclage (TAC), which is reserved for highly selected women with recurrent mid-trimester pregnancy loss, due to cervical insufficiency.

METHODS

A retrospective audit covering 25 years (January 1, 1997 to December 31, 2021) was performed at the Obstetric Special Care division, Tygerberg Academic Hospital in Cape Town, South Africa. All 118 pregnancies from 94 procedures, operated and managed by the principal author were included for descriptive analysis.

RESULTS

Eighty-four (91.3%) of the 92 first pregnancies after first insertion had successful outcomes. All second and third pregnancies (24/24; 100%) were successful. Eight pregnancies did not achieve viability, two women (2/8) did however achieve a successful pregnancy after a subsequent repeat TAC procedure. For the viable pregnancies (110/118), the median gestational age at delivery was 37 weeks (range 28-39 weeks). The median intraoperative blood loss during cerclage insertion was 100 ml (range 25-750 ml).

CONCLUSION

In experienced hands, TAC during pregnancy is a safe and effective operation, when other less invasive procedures have failed.

Progesterone, cerclage, pessary, or acetylsalicylic acid for prevention of preterm birth in singleton and multifetal pregnancies - A systematic review and meta-analyses

Background

Preterm birth is the leading cause of childhood mortality and morbidity. We aimed to provide a comprehensive systematic review on randomized controlled trials (RCTs) on progesterone, cerclage, pessary, and acetylsalicylic acid (ASA) to prevent preterm birth in asymptomatic women with singleton pregnancies defined as risk of preterm birth and multifetal pregnancies.

Methods

Six databases (including PubMed, Embase, Medline, the Cochrane Library) were searched up to February 2022. RCTs published in English or Scandinavian languages were included through a consensus process. Abstracts and duplicates were excluded. The trials were critically appraised by pairs of reviewers. The Cochrane risk-of-bias tool was used for risk of bias assessment. Predefined outcomes including preterm birth, perinatal/neonatal/maternal mortality and morbidity, were pooled in meta-analyses using RevMan 5.4, stratified for high and low risk of bias trials. The certainty of evidence was assessed using the GRADE approach. The systematic review followed the PRISMA guideline.

Results

The search identified 2,309 articles, of which 87 were included in the assessment: 71 original RCTs and 16 secondary publications with 23,886 women and 32,893 offspring. Conclusions were based solely on trials with low risk of bias (n = 50).Singleton pregnancies: Progesterone compared with placebo, reduced the risk of preterm birth <37 gestational weeks: 26.8% vs. 30.2% (Risk Ratio [RR] 0.82 [95% Confidence Interval [CI] 0.71 to 0.95]) (high certainty of evidence, 14 trials) thereby reducing neonatal mortality and respiratory distress syndrome. Cerclage probably reduced the risk of preterm birth <37 gestational weeks: 29.0% vs. 37.6% (RR 0.78 [95% CI 0.69 to 0.88]) (moderate certainty of evidence, four open trials). In addition, perinatal mortality may be reduced by cerclage. Pessary did not demonstrate any overall effect. ASA did not affect any outcome, but evidence was based on one underpowered study.Multifetal pregnancies: The effect of progesterone, cerclage, or pessary was minimal, if any. No study supported improved long-term outcome of the children.

Conclusion

Progesterone and probably also cerclage have a protective effect against preterm birth in asymptomatic women with a singleton pregnancy at risk of preterm birth. Further trials of ASA are needed. Prevention of preterm birth requires screening programs to identify women at risk of preterm birth.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021234946].

The effectiveness of transabdominal cerclage placement via laparoscopy or laparotomy: a systematic review and meta-analysis

OBJECTIVE

Failure or technical impossibility to place a prophylactic transvaginal cerclage in women with cervical insufficiency justifies the need for an abdominal cerclage. In this systematic review and meta-analysis, we studied the obstetrical and surgical outcomes of laparoscopic and open laparotomy abdominal cerclage approaches performed before (interval) or during pregnancy.

DATA SOURCES

We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for studies on laparoscopic and open laparotomy abdominal cerclage placement in February 2022.

STUDY ELIGIBILITY CRITERIA

All studies on laparoscopic or open laparotomy placement of an abdominal cerclage with at least 2 patients that reported on our primary outcomes were included.

METHODS

All included studies were assessed for quality and risk of bias with an adjusted Quality in Prognosis Study tool. Random effects meta-analyses were performed for the primary outcomes, namely fetal survival and gestational age at delivery.

RESULTS

Our search yielded 83 studies with a total of 3398 patients; 1869 of those underwent laparoscopic cerclage placement and 1529 underwent open laparotomy placements. No studies directly compared the 2 cerclage approaches. The survival (overall, 91.2%) and gestational age at delivery (overall, 36.6 weeks) were not statistically different between the approaches. For the procedure during pregnancy, the laparoscopic group showed significantly less blood loss >400 mL (0% vs 3%), a slightly lower procedure-related fetal loss (0% vs 1%), a shorter hospital stay but a longer operation duration than the open laparotomy group. For the interval cerclages, the laparoscopic group showed significantly fewer wound infections (0% vs 3%) and a shorter hospital stay than the open laparotomy group, but showed comparable offspring preterm birth and survival rates.

CONCLUSION

Based on indirect comparisons, the laparoscopic and open laparotomy abdominal cerclage placements at interval or during pregnancy produced similar outcomes in terms of survival and gestational age at delivery. There are some small differences in perioperative care, surgical complications, interventions, and complications during pregnancy. This implies that both methods of abdominal cerclage placement have high success rates and thus we cannot conclude that one of the methods is superior for the placement of an abdominal cerclage.

Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre

Background

Cervical cerclage has been proposed as an effective treatment for cervical insufficiency, but there has been controversy regarding the surgical options of cervical cerclage in singleton and twin pregnancies. This study aimed to compare the pregnancy outcomes between transvaginal cervical cerclage (TVC) and laparoscopic abdominal cervical cerclage (LAC) in patients with cervical insufficiency. We also aimed to evaluate the efficacy and safety, and provide more evidence to support the application of cervical cerclage in twin pregnancies.

Methods

A retrospective study was carried out from January 2015 to December 2021. The primary outcomes were the incidence of spontaneous preterm birth (sPTB) < 24 weeks, < 28, < 32, < 34 weeks, and < 37weeks, gestational age at delivery, and the incidence of admission for threatened abortion or preterm birth after cervical cerclage. The secondary outcomes included admission to the Neonatal Intensive Care Unit, adverse neonatal outcomes and neonatal death. We also analysed the pregnancy outcomes of twin pregnancies after cervical cerclage.

Results

A total of 289 patients were identified as eligible for inclusion. The LAC group (n = 56) had a very low incidence of sPTB ˂ 34 weeks, and it was associated with a significant decrease in sPTB < 28 weeks, ˂32 weeks, ˂34 and < 37 weeks, and admission to the hospital during pregnancy for threatened abortion or preterm birth after cervical cerclage (0 vs.27%; 1.8% vs. 40.3%; 7.1% vs. 46.8%; 14% vs. 63.5%, 8.9% vs. 62.2%, respectively; P < 0.001), and high in gestational age at delivery compared with the TVC group (n = 233) (38.3 weeks vs.34.4 weeks,P < 0.001). Neonatal outcomes in the LAC group were significantly better than those in the TVC group. The mean gestational age at delivery was 34.3 ± 1.8 weeks, with a total foetal survival rate of 100% without serious neonatal complications in twin pregnancies with LAC.

Conclusion

In patients with cervical insufficiency, LAC appears to have better pregnancy outcomes than TVC. For some patients, LAC is a recommended option and may be selected as the first choice. Even in twin pregnancies, cervical cerclage can improve pregnancy outcomes with a longer latency period, especially in the LAC group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05108-w.

Endoscopic transabdominal cervical cerclage replacement after recurrent late miscarriage

Transabdominal cerclage (TAC) is a recognised treatment for recurrent spontaneous late miscarriage or preterm birth due to cervical weakness. This can be performed via an open procedure before and during pregnancy, or a laparoscopic technique preconception. Complications include cerclage failure and suture migration. We present a case highlighting these complications where laparoscopic removal of an open TAC and replacement led to two successful term deliveries. A woman in her thirties with a fibroid uterus, adenomyosis and a history of three spontaneous mid-trimester losses, had an open TAC at 13 weeks of gestation. Preterm premature rupture of the membranes occurred shortly after and at 18 weeks of gestation she underwent surgical evacuation of the uterus. Subsequent hysteroscopy confirmed migration of the cerclage through the cervical canal. We demonstrate the application of endoscopic gynaecological surgery to remove and replace the TAC with two successful term births by Caesarean section in the ensuing pregnancies.

Controversies in treatment practices of the mother-infant dyad at the limit of viability

In the setting of threatened extreme preterm birth, balancing maternal and fetal risks and benefits in order to choose the best available treatment options is of utmost importance. Inconsistency in treatment practices for infants born between 22 and 24 weeks of gestatotional age may account for inter-hospital variation in survival rates with and without impairment. Most importantly, non-biased and accurate information must be presented to the family as soon as extremely preterm birth is suspected, including counseling on morbidities and mortality associated with delivery at the limits of viability. This review will focus on different therapeutic medical and surgical practices available for threatened extremely preterm birth to improve fetal and maternal outcomes while highlighting the importance of patient-centered approaches.

Efficacy of laparoscopic and trans-abdominal cerclage (TAC) in patients with cervical insufficiency: A systematic review and meta-analysis

BACKGROUND

Cervical insufficiency (CI) may result in preterm delivery. We sought out to perform this review and analysis to compare the efficacy of laparoscopic and open transabdominal cerclage (TAC) in patients suffering with CI.

METHODS

Our search included PubMed, Scopus, MEDLINE, ClinicalTrials.Gov, Cochrane and Web of Science. We analyzed the data with Open Meta-Analyst Software as well as Review Manager Software. We included observational and randomized controlled trials that included patients with CI that underwent laparoscopic cerclage or TAC.

RESULTS

We included a total of 43 studies. Laparoscopic and TAC had a positive effect by increasing gestational age (GA); for the laparoscopic group (mean deviation (MD)) = 14.86 weeks (W), 95% CI [10.67, 19.05], P < 0.001) and TAC (MD = 12.79 W, 95% CI [10.97, 14.61], P < 0.001). Furthermore, improvements in all outcomes assessed (total fetal survival rate, neonatal weight, and prevention of delivery at a gestational age of<24 weeks) were all significant with the exception of the prevention of all preterm deliveries<37 weeks; for both laparoscopic at (RR = 0.116, 95% CI [-0.006, 0.238], P = 0.063) and TAC at (MD = 1, 95% CI [0.45, 2.24], P = 1), and for prevention of deliveries<34 weeks for the laparoscopic group (RR = 0.446, 95% CI [-0.323, 1.215], P = 0.256) only.

CONCLUSIONS

Although limited data prevented pregnancy and prepregnancy subgroups as well as a head-to-head comparison, we still found that in patients suffering from CI, both TAC and laparoscopic approaches to cerclage revealed a positive effect in preserving the pregnancy.

A modified transabdominal cervicoisthmic cerclage with the monofilament thread: Its efficacy and safety for women with extremely short cervix due to cervical conization

AIM

The study aimed to examine the usefulness of modified transabdominal cervicoisthmic cerclage (TAC) using monofilament thread for the prevention of preterm delivery in women with an extremely short cervix after deep conization.

METHODS

We devised a monofilament thread for picking up the seromuscular layer of the site that is slightly cephalad to the internal ostium to prevent injury of the vessels around the uterine cervix. From 2017 to 2020, we performed this modified operation in eight women (nine pregnancies) at 12-16 weeks of gestation with a history of deep cervical conization.

RESULTS

A modified TAC was successfully performed in all patients. There was no measurable bleeding, and all patients were discharged without postoperative complications. Their pregnancy courses after the operation were uneventful. Of nine, one patient had premature uterine contractions and underwent cesarean section at 36 weeks (preterm delivery). In the other eight pregnancies, planned cesarean section was performed after 37 weeks of gestation. The median birth weight of the babies was 2996 g (range 2604-3374 g). All patients were discharged on the sixth postoperative day without complications.

CONCLUSION

A modified TAC can be safely performed and may prolong pregnancy without adverse events in patients with an extremely short cervix.

Number and quality of randomized controlled trials in obstetrics published in the top general medical and obstetrics and gynecology journals

BACKGROUND

There has been an increasing number of randomized controlled trials published in obstetrics and maternal-fetal medicine to reduce biases of treatment effect and to provide insights on the cause-effect of the relationship between treatment and outcomes.

OBJECTIVE

This study aimed to identify obstetrical randomized controlled trials published in top weekly general medical journals and monthly obstetrics and gynecology journals, to assess their quality in reporting and identify factors associated with publication in different journals.

STUDY DESIGN

The 4 weekly medical journals with the highest 2019 impact factor (New England Journal of Medicine, The Lancet, The Journal of the American Medical Association, and British Medical Journal), the top 4 monthly obstetrics and gynecology journals with obstetrics-related research (American Journal of Obstetrics & Gynecology, Ultrasound in Obstetrics & Gynecology, Obstetrics & Gynecology, and the British Journal of Obstetrics and Gynaecology), and the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine were searched for obstetrical randomized controlled trials in the years 2018 to 2020. The primary outcome was the number of obstetrical randomized controlled trials published in the obstetrics and gynecology journals vs the weekly medical journals and the percentage of trials published, overall and per journal. The secondary outcomes included the proportion of positive vs negative trials overall and per journal and the assessment of the study characteristics of published trials, including quality assessment criteria.

RESULTS

Of the 4024 original research articles published in the 9 journals during the 3-year study period, 1221 (30.3%) were randomized controlled trials, with 137 (11.2%) randomized controlled trials being in obstetrics (46 in 2018, 47 in 2019, and 44 studies in 2020). Furthermore, 33 (24.1%) were published in weekly medical journals, and 104 (75.9%) were published in obstetrics and gynecology journals. The percentage of obstetrical randomized controlled trials published ranged from 1.5% to 9.6% per journal. Overall, 34.3% of obstetrical trials were statistically significant or "positive" for the primary outcome. Notably, 24.8% of the trials were retrospectively registered after the enrollment of the first study patient. Trials published in the 4 weekly medical journals enrolled significantly more patients (1801 vs 180; P<.001), received more often funding from the federal government (78.8% vs 35.6%; P<.001), and were more likely to be multicenter (90.9% vs 42.3%; P<.001), non-United States based (69.7% vs 49.0%; P=.03), and double blinded (45.5% vs 18.3%; P=.003) than trials published in the obstetrics and gynecology journals. There was no difference in study type (noninferiority vs superiority) and trial quality characteristics, including pretrial registration, ethics approval statement, informed consent statement, and adherence to the Consolidated Standards of Reporting Trials guidelines statement between studies published in weekly medical journals and studies published in obstetrics and gynecology journals.

CONCLUSION

Approximately 45 trials in obstetrics are being published every year in the highest impact journals, with one-fourth being in the weekly medical journals and the remainder in the obstetrics and gynecology journals. Only about a third of published obstetrical trials are positive. Trials published in weekly medical journals are larger, more likely to be funded by the government, multicenter, international, and double blinded. Quality metrics are similar between weekly medical journals and obstetrics and gynecology journals.

FIGO good practice recommendations on cervical cerclage for prevention of preterm birth

Cervical cerclage is an intervention which when given to the right women can prevent preterm birth and second‐trimester fetal losses. A history‐indicated cerclage should be offered to women who have had three or more preterm deliveries and/or mid‐trimester losses. An ultrasound‐indicated cerclage should be offered to women with a cervical length <25 mm if they have had one or more spontaneous preterm birth and/or mid‐trimester loss. In high‐risk women who have not had a previous mid‐trimester loss or preterm birth, an ultrasound‐indicated cerclage does not have a clear benefit in women with a short cervix. However, for twins, the advantage seems more likely at shorter cervical lengths (<15 mm). In women who present with exposed membranes prolapsing through the cervical os, a rescue cerclage can be considered on an individual case basis, taking into account the high risk of infective morbidity to mother and baby. An abdominal cerclage can be offered in women who have had a failed cerclage (delivery before 28 weeks after a history or ultrasound‐indicated [but not rescue] cerclage). If preterm birth has not occurred, removal is considered at 36–37 weeks in women anticipating a vaginal delivery.

Cervical cerclage given to the right women can prevent preterm birth and second‐trimester fetal losses.

Development of a video to teach clinicians how to perform a transabdominal cerclage

BACKGROUND

A transabdominal cerclage has been shown in a recent randomized controlled trial to be superior to a low vaginal cerclage in reducing the risk of early preterm birth (8% [3/39] vs 33% [11/33]; relative risk, 0.23; 95% confidence interval, 0.07-0.76; P=.01570) and fetal loss (3% [1/39] vs 21% [7/33]; relative risk, 0.12; 95% confidence interval, 0.016-0.930) in women with a previous failed vaginal cerclage.¹ OBJECTIVE: We sought to create a video illustrating a transabdominal cerclage procedure for use as a teaching resource and describing this uncommon but important procedure for dissemination among clinicians.

STUDY DESIGN

Transabdominal cerclage insertion in a non-gravid and gravid uterus (less than 14 weeks' gestation) via laparotomy and laparoscopy was filmed with patients' and clinicians' consent in main theatres at St Thomas' Hospital and University College London Hospital. The film footage was edited, and an audio narration by the surgeon was included to provide a description of the procedures.

RESULTS

We developed an 8-minute video with an audio narration describing the insertion and management issues of an abdominal cerclage for free dissemination among clinicians who wish to learn how to perform this procedure.

CONCLUSION

An abdominal cerclage has been shown to significantly reduce early preterm birth and fetal loss more effectively than a low vaginal cerclage in women with a previous failed cerclage. More obstetricians and gynecologists need to be trained on how to perform the transabdominal cerclage procedure to increase its availability to suitable women. This procedure is technically straightforward and can be taught via video, which can easily be shared among clinicians at a low cost.

Transabdominal cerclage in early pregnancy for cervical shortening after radical trachelectomy: A case report

Radical trachelectomy (RT) is a method of fertility preservation for patients with early invasive uterine cervical cancer stage IA2 or IB1 with a tumor diameter of ≤2 cm. However, women who have undergone RT have high risks of abortion and premature birth. To prevent premature birth, cervical cerclage is performed in patients with an ultra-short cervix, but the portio vaginalis is not visible in these patients, and transvaginal uterine cervical cerclage is almost impossible. In such cases, transabdominal cerclage (TAC) is considered. The patient reported here was a 39-year-old Japanese woman, gravida 2, para 0. At 37 years, she was diagnosed with cervical cancer, stage IB1 (according to the International Federation of Gynecology and Obstetrics [FIGO] classification), so abdominal modified RT was performed. One year after the operation, she became pregnant through in vitro fertilization and embryo transfer. The cervical length was 17 mm at 13 weeks of gestation but was shortened to 5 mm at 16 weeks of gestation, so TAC was performed. An emergency cesarean section was performed because of increased genital bleeding at 34 weeks of gestation and a live baby was delivered.

•

Radical trachelectomy is used in women with early invasive uterine cervical cancer who wish to retain their fertility.

•

Women who have undergone radical trachelectomy are at increased risk of pregnancy loss and premature birth.

•

Transabdominal cerclage was undertaken at 16 weeks of gestation.

•

Emergency cesarean section delivery of a live infant was undertaken at 34 weeks due to vaginal bleeding.

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.

Fertility outcomes after preconceptional laparoscopic abdominal cerclage for second-trimester pregnancy losses

OBJECTIVE(S)

Cervical incompetence is an important cause of recurrent pregnancy loss, typically presenting in the second trimester with silent cervical dilation and premature delivery of the fetus. We aimed to evaluate the conception rate and time to conception or failure to conceive after preconceptional laparoscopic abdominal cerclage (LAC).

STUDY DESIGN

We conducted this retrospective observational cohort study at a tertiary referral center. Patients who underwent LAC in the nonpregnant state for a second-trimester pregnancy loss between June 2012 and February 2020 were included.

RESULTS

The subjects were 40 patients with a history of one or more second-trimester pregnancy losses despite the placement of vaginal cerclage, who had undergone LAC before contemplating a future pregnancy. The mean number of second-trimester pregnancy losses before LAC was two per woman. The ages of the women at the time of cerclage ranged from 21 to 42 years. The time to pregnancy, which was the primary outcome of the study, was determined as the number of menstrual cycles before the patient became pregnant after LAC and the number of cycles needed for the patient to achieve her latest pregnancy before LAC. Of the 40 women, 22.5 % were noted during the LAC operation to have a pelvic peritoneal pathology that might have affected fertility, and all such pathologies were treated concomitantly during the procedure. Spontaneous pregnancy rates before and after LAC were 96.4 % and 89.3 % (p = 0.299), and times to pregnancy before and after LAC were 6.3 ± 8.4 and 6.6 ± 8.1 cycles (p = 0.897). Neither difference was statistically significant. In more than 84 % of patients who became pregnant after LAC, pregnancy was sustained to the stage of viability.

CONCLUSION(S)

In patients with cervical incompetence, LAC is a very effective intervention to sustain pregnancy to the stage of viability. If placed during the preconceptional period, it does not delay achieving pregnancy and does not have a negative impact on the chances of conception. This may be reassuring to women undergoing this procedure before they achieve a pregnancy.

Complications of Laparoscopic and Transabdominal Cerclage in Patients with Cervical Insufficiency: A Systematic Review and Meta-analysis

OBJECTIVE

Cervical insufficiency is a defect of the cervix that leads to failure to preserve a full-term intrauterine pregnancy. Laparoscopic cerclage and open transabdominal cerclage (TAC) are effective ways to manage patients with cervical insufficiency. We performed this systematic review and meta-analysis to investigate the complications of laparoscopic cerclage and open TAC in the management of cervical insufficiency.

DATA SOURCES

We searched PubMed, Cochrane, Scopus, and Web of Science using our search strategy and screened the results for our criteria. We extracted the results reported and analyzed them using Open Meta-Analyst (OpenMeta[Analyst], Brown School of Public Health, Providence, RI) and Review Manager (Cochrane Collaboration, London, United Kingdom) software.

METHODS OF STUDY SELECTION

We included all randomized controlled and observational trials performed on patients with cervical insufficiency undergoing open TAC or laparoscopic cerclage that matched our search strategy. We excluded letters to the editor, reviews, meetings/conference abstracts, non-English or nonhuman studies, and instances where the full text was not available.

TABULATION, INTEGRATION, AND RESULTS

We included a total of 33 trials. Both interventions of laparoscopic cerclage and open TAC were associated with significantly less total fetal loss (laparoscopic cerclage, relative risk [RR] 0.03; 95% confidence interval [CI], 0.01-0.08; p <.001, and open TAC, RR 0.19; 95% CI, 0.07-0.51; p <.009). The overall blood loss in open TAC was 110.589 mL (95% CI, 93.737-127.44; p <.001), and in laparoscopic cerclage, it was 24.549 mL (95% CI, 9.892-39.205; p = .001). In addition, open TAC had a positive effect regarding incidence of hemorrhage >400 mL (RR 0.077; 95% CI, 0.033-0.122; p <.001). Preterm premature rupture of membranes was significant in the open TAC (RR 0.037; 95% CI, 0.019-0.055; p <.001) and laparoscopic cerclage groups (RR 0.031; 95% CI, 0.009-0.053; p = .006).

CONCLUSION

Laparoscopic cerclage may be safer than open TAC in the management of cervical insufficiency because we found a statistically significant lower incidence of fetal loss, blood loss, and rate of hemorrhage in the laparoscopic cerclage group. Clinically, this evidence may help support favoring a laparoscopic approach over an open one in appropriate patients, although it is unclear whether this benefit is limited to cerclages placed either before pregnancy or placed in the first-trimester or both.

Comparison of laparoscopic abdominal cerclage and transvaginal cerclage for the treatment of cervical insufficiency: a retrospective study

PURPOSE

To compare the pregnancy outcome of patients with cervical insufficiency (CI) underwent prophylactic laparoscopic abdominal cervical cerclage (LAC) and transvaginal cervical cerclage (TVC).

METHODS

A retrospective trial was carried out in the Department of Gynecology, Qingdao Women and Children's Hospital, Shandong Province, China. A total of 217 women with cervical insufficiency underwent the prophylactic cerclage, and the surgical approach was decided by the patients or depended on doctors' advice. The primary outcome measure was the fetal outcome. Secondary outcome measures were delivery of an infant at ≥ 34th gestational weeks, newborn birth weight, neonatal intensive care center (NICU) occupancy, and postoperative complications. Nonparametric variables were analyzed with the Mann-Whitney (U) test, and categorical type outcomes were analyzed with the Chi-square test or the Fisher's exact test. A P value < 0.05 was considered significant. Data analysis was performed using SPSS Statistics Version 19.

RESULTS

As of follow-up date, 154 eligible patients were included in this study, with 74 (48.1%) women in the LAC group and 80 (51.9%) in the TVC group. The total fetal survival rate in the two groups was 90.3% (139/154), of which the rate significantly higher in the LAC group compared to the TVC group (97.3% vs. 83.8%, P < 0.01). The delivery of an infant at ≥ 34th gestational weeks was significantly higher in the LAC group compared to the TVC group (94.6% vs. 71.3%, P < 0.01). Compared to the TVC group, the mean newborn birth weight was higher, and the NICU occupancy rate was less in the LAC group (3293.4 ± 542.8 g vs. 2953.6 ± 704.4 g, P = 0.002; 2.8% vs. 17.9%, P = 0.003).

COMPLICATIONS

No fatal surgical complications occurred in both groups.

CONCLUSION

In patients with cervical insufficiency, the history-indicated conception of prophylactic LAC appears to have a better pregnancy outcome than TVC.

Prevention of preterm birth: Proactive and reactive clinical practice-are we on the right track?

Preterm birth remains the major cause of death and disability among children under the age of five. In developing countries antenatal preterm birth prevention clinics are set up to provide cervical length surveillance and/or treatment modalities such as cerclage or progesterone for those women with identified risk factors such as previous cervical treatment or preterm birth. However, 85% of women have no risk factors for PTB and currently there is no biomarker to screen women early in pregnancy. Women will present unexpectedly in threatened preterm labour and we have no choice but to adopt a re-active approach to their care by using predication and preparation strategies such as fetal fibronectin, tocolytic therapy and steroids. Despite these strategies approximately 15-20% of these women will give birth preterm before 34 weeks. There is a urgent need to re-design primary, secondary and tertiary prevention strategies for spontaneous preterm labour (sPTL) in singleton pregnancies aimed at identifying and addressing key gaps in clinical practice and research.

Anatomical and functional changes in arteries of uterine circulation after modified laparoscopic transabdominal cerclage in pregnancy: A case report and review of the literature

Modified laparoscopic transabdominal cerclage (LTAC) was developed as a safer approach for the treatment of cervical insufficiency in pregnancy, with the cerclage tape placed lateral to the uterine vessels. We describe and review the evolution of a woman who successfully underwent an LTAC at 12 weeks of gestation, whose fetus developed growth retardation after 32 weeks. Three-dimensional power Doppler reconstruction viewed both uterine arteries (UtAs) inside of the cerclage until the second trimester. Thereafter, the visualization of UtAs showed the development of a rich array of collateral vascularization, adaptation supported by the findings of low velocity and pulsatility of blood flow in the UtAs. The appearance of the UtAs varies throughout the gestation. There is a moderate variation of the shape and curvature that could result due to their elongation. Furthermore, the cervical length increased during gestation, from 20 to 30 mm. We speculate that this is a mechanical modeling during the late gestation. More studies are needed to understand the hemodynamic and mechanical effects as well as the impact on fetal growth and development of modified LTAC in women with a short cervix or cervical incompetence.

Removal of an Abdominal Cerclage by Colpotomy: A Novel and Minimally Invasive Technique

Abdominal cerclage is an effective treatment for cervical incompetence in patients with a previously failed vaginal cerclage or with anatomic restrictions to a vaginal cerclage. Management of second trimester complications that warrant a delivery impose a complex clinical situation in patients with an abdominal cerclage. We report 3 cases of successful removal of an abdominal cerclage by posterior and anterior colpotomy in the second trimester of pregnancy. This new and minimally invasive surgical technique avoids the need for extensive dilation, laparoscopy, or laparotomy to remove the cerclage and allow a vaginal delivery.

The experience and outcomes of a specialised preterm birth clinic in New Zealand

BACKGROUND

A greater understanding of the risk factors for spontaneous preterm birth and the importance of risk stratification to guide interventions has led to the introduction of preterm birth prevention clinics.

AIM

To evaluate the experience and outcomes of the first specialised preterm birth clinic in New Zealand.

MATERIALS AND METHODS

This observational study reviewed pregnancies cared for in a preterm birth clinic from 2013 to 2018. Cases were identified and data collected from a maternity database and electronic medical records. Analysis was by referral type.

RESULTS

A total of 423 cases were included; 309 elective and 22 acute referrals in pregnancy, and 92 consultations outside pregnancy. For those referred electively in pregnancy, 138/309 (44.7%) fulfilled multiple referral criteria, and 57/309 (18.4%) had ≥2 previous spontaneous preterm births or second trimester losses. Excluding five pregnancies with first trimester miscarriage, 77/304 (25.3%) were managed with a history-indicated cerclage (11 placed pre-conception) and 217/304 (71.4%) had cervical surveillance as primary management, of which 133 (61.3%) did not require treatment. The remaining had treatment for a short cervix; 37 (17.0%) received an ultrasound-indicated cerclage only, 21 (9.7%) vaginal progesterone only and 26 (12.0%) both. Five women (1.6%) had a second trimester loss at 13⁺⁰ -19⁺⁶ and 58/297 (19.5%) had a spontaneous preterm birth at 20⁺⁰ -36⁺⁶  weeks. The 'take home baby' rate was 95.4%.

CONCLUSIONS

Pregnancy outcomes were similar to those reported by other preterm birth prevention clinics. The majority of women who received cervical surveillance as primary management were able to avoid additional treatment.