Predictors of Outcomes of Non-Elective Cervical Cerclages

Perinatal outcomes of emergency and elective cervical cerclages

Objective

This study aims to compare the perinatal outcomes of emergency and elective cervical cerclages.

Material and Methods

This retrospective study included a total of 247 patients, with a total of 142 emergency (with a history of mid-trimester miscarriage or vaginal delivery of < 34 weeks and cervical length < 25 mm) and 105 electives cerclage patients (with painless cervical dilation and cervical length <25 mm) who had cerclage with the vaginal cervical McDonald technique between 1.1.2017-1.10.2022. Pregnant women with normal screening tests at weeks 11-14, normal fetal morphology, and singleton pregnancies were included in the study. The study was conducted in a tertiary center providing NICU care for < 1500 g, less than 32 weeks of age, and on a mechanical ventilator. Obstetric and perinatal outcomes were reviewed.

Results

There was no statistical difference between the two groups regarding maternal age or BMI. It was observed that the week of delivery was greater for elective cerclages than for emergency cerclages (mean 34.6 GW versus 30.8 GW). The week of cerclage application was statistically higher in emergency cerclage (19.2 GW versus 16.3 GW p < 0.000). In addition, when we evaluated perinatal complications: prenatal Ex (n34 vs. n8 p < 0.001), C-reactive protein which is a marker of neonatal infection (12.7 mg/L vs. 2.5 mg/L p < 0.022), antibiotic use in the NICU (n 35 vs. n23 p < 0.050), the number of days of antibiotic use in the NICU (mean 15.3 days vs. 10.4 days p < 0.024), rate of NICU intubation (n 27 vs. n 11 p < 0.003), and neonatal sequelae (n 16 vs. n 6 p < 0.016) were significantly higher in the emergency cerclage group than in the elective cerclage group. There was no found significant difference between the progesterone given and not given progesterone after the procedure in term of the weeks of delivery (p < 0.810 emergency cervical cerclage; p < 0681 elective cervical cerclage).

Conclusion

Considering the available information, the results of elective cerclage seem to be more beneficial for the patient than those of emergency cerclage. Therefore, it would be more reasonable to perform elective cerclage in patients with mid-trimester or preterm miscarriage and concomitant cervical shortening before emergency cerclage is required. Furthermore, the benefit of progestin, in addition after surgical intervention, has not been established.

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.

Body mass index and adverse outcomes among singletons with cerclage

OBJECTIVE

To compare the neonatal and maternal adverse outcomes among women with cerclage and prepregnancy body mass index (BMI) < versus > 30 kg/m² STUDY DESIGN: This retrospective cohort study utilized the U.S. Vital Statistics Datasets from 2011-2013. Inclusion criteria were women with non-anomalous singletons, with cerclage placement, without diabetes or hypertensive disorders, and who delivered at 20-41 weeks. The primary outcome was the composite neonatal adverse outcome (Apgar score below 5 at 5 min, birth injury, assisted ventilation for more than 6 h, neonatal seizure, or neonatal death). The secondary outcomes included the composite maternal adverse outcome (admission to intensive care unit, maternal transfusion, ruptured uterus, unplanned hysterectomy, or unplanned operating room procedure), chorioamnionitis, and cesarean delivery. Multivariable Poisson regression models with robust error variance were used, while adjusting for confounders. Adjusted relative risk with 95 % confidence intervals were calculated.

RESULTS

Of the 22,466 live births that met the inclusion criteria during the study period, 6427 (28.6 %) had cerclage and prepregnancy BMI ≥ 30 kg/m². The composite neonatal adverse outcome was significantly increased (aRR 1.45; 95 % CI 1.33-1.60) among women with cerclage and BMI ≥ 30 kg/m² when compared to those with BMI < 30 kg/m². The composite maternal adverse outcome was similar (aRR 0.93; 95 % CI 0.72-1.20) among the two groups. Chorioamnionitis (aRR 1.46; 95 % CI 1.24-1.72) and cesarean delivery (aRR 1.24; 95 % CI 1.19-1.29) were higher in women with cerclage and BMI ≥ 30 kg/m².

CONCLUSION

Among pregnancies with cerclage and delivery at 20-41 weeks, the risk of the composite neonatal adverse outcome was modestly increased in newborns delivered by women with BMI ≥ 30 kg/m² than those delivered by women with BMI < 30 kg/m². No significant difference was found in the risk of the composite maternal adverse outcome.

Emergency cerclage following a standardized protocol offers an effective and safe therapeutic option for women with high risk for prematurity - a retrospective monocentric cohort study on 130 pregnancies and 155 neonates

Objective: To present emergency cerclage (EC) as a safe and effective therapeutic option for prevention of prematurity in women with advanced cervical dilation in second-trimester pregnancy. It is focused on seemingly futile situations like cervical dilation >5 cm, bulging membranes and multifetal pregnancies. The outcomes of interest are the prolongation of pregnancy, gestational age at delivery and neonatal morbidity and mortality related to distinct risk factors.Study design: Retrospective monocentric cohort study involving 130 pregnancies (105 single and 25 twin pregnancies) and 155 neonates by using a standardized protocol. Women between 18 and 28 gestational weeks with cervical shortening of <10 mm + cervical dilation >2 cm and/or bulging membranes were included. Analyses of maternal and neonatal parameters were done by chart review.Results: The medium gestational age at delivery was 35 5/7 week with a medium interval from cerclage placement to delivery of 83 days. Overall, 46.5% (72/155) neonates were born beyond 37 weeks, extreme prematurity of less than 28 gestational weeks was observed in 14.8% (23/155), no miscarriage before 22 weeks was documented. The neonatal mortality was 1.9% (3/155). Neonatal deaths and morbidity was related to severe prematurity exclusively. The association of amnion-infection syndromes and failing therapy was significantly with respect to bulging membranes and advanced cervical dilation >5 cm.Conclusions: Even in futile cases EC can be an option to save the pregnancy and prevent severe prematurity. However, a standardized protocol is imminent for successful therapy and every indication has to be a case by case decision.

Effectiveness and safety of late midtrimester cervical cerclage

Objectives: To evaluate the safety and effectiveness of late cervical cerclage performed beyond 17 weeks of gestation. The outcomes of interest were effectiveness of late cerclage in prolongation of pregnancy and evaluation of pregnancy outcome including maternal and fetal complications. Study design: A total of 30 patients underwent late cervical cerclage during the study period. Of them, two were twin pregnancies. A late cerclage was performed after the diagnosis of cervical shortening or dilatation in 20 patients. We performed a retrospective case series review. One case was lost to follow up (delivery in another medical center). Medical information was retrieved from all cases of patients who underwent a late cervical cerclage between the years 2010 and 2016 at the Soroka University Medical Center, a tertiary medical center. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as proportions. Results: The average gestational age at birth was 35 ± 5.1 weeks of gestation. The mean interval between cerclage and delivery in the study population was 17 ± 5.62 weeks. Nine cases (32.1%) resulted in preterm deliveries, three of them below 34 weeks of gestation (one twin pregnancy and two pregnancies diagnosed with cervical dilation prior to cerclage). Among all the preterm deliveries, there were four cases of preterm prelabor rupture of membranes (13.3%). Of the 28 deliveries, 24 women (85.7%) had a vaginal delivery, while four women (14.3%) underwent a cesarean section. No cases of cervical tear were described. The cerclage was sent to bacteriology after removal, showing positive cultures for Candida species in nine cases (31%). Conclusions: In our study population, late cervical cerclage was found to be a safe procedure resulting in almost 90% of successful vaginal deliveries without maternal or fetal complications. This procedure might be effective in the prolongation of pregnancy in women with cervical dynamics in the late second trimester.

Clinical effect of emergency cervical cerclage and elective cervical cerclage on pregnancy outcome in the cervical-incompetent pregnant women

PURPOSE

To compare the clinical effect of emergency cervical cerclage and elective cervical cerclage on pregnancy outcome in the cervical-incompetent pregnant women.

METHODS

Literature was searched from the databases of Pubmed, Embase and Google scholar. The fixed or random effects model was used to calculate pooled risk ratios on the basis of heterogeneity. Meta-regression, sensitive analysis, subgroup analysis, and publication bias assessment were also conducted to confirm the results according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009.

RESULTS

The meta-analysis results showed that there were significant associations between cerclage operations and pregnancy outcomes in gestation age, birth weight, and PROM rate. Gestation age was significantly higher in women with elective cerclage than those with emergency cerclage, and birth weight was significantly higher in newborns for the elective group as compared with emergency group. The rate of PROM in elective group was lower than emergency group. However, there were no differences between the emergency cerclage group and the elective cerclage group regarding the rate of vaginal delivery.

CONCLUSIONS

This meta-analysis suggests that emergency cerclage has lower gestation age and birth weight than elective cerclage, and it increases the risk of PROM. Further well-designed studies are warranted to confirm these results.

Anterior uterocervical angle measurement improves prediction of cerclage failure

OBJECTIVE

To compare the anterior uterocervical angle and cervical length as predictors of spontaneous preterm delivery in patients with transvaginal cerclage.

STUDY DESIGN

We retrospectively evaluated a cohort of 142 pregnant women with transvaginal cerclage placed over a 5-year period (2010 to 2015) were evaluated. Cervical morphology characteristics were measured from endovaginal imaging, including cervical length, cerclage height, funnel volume and anterior uterocervical angle prior to cerclage placement (UCA 1), shortly after cerclage placement (UCA 2) and the last image prior to delivery (UCA 3). Cerclage failure was defined as delivery prior to 36 weeks. Univariate analysis, receiver operator characteristic curves and binary logistic regression were used for statistical analysis. Statistical significance was defined as a P<0.05.

RESULTS

Among the 142 women with a transvaginal cerclage, 38% had cerclage failure. The mean gestational age at birth was 29.3±5.2 weeks in the failure group compared with 37.9±2.8 weeks in those that did not fail (P<0.001). Univariate analysis identified cervical length (P=0.034) and UCA 3 (P<0.001) as significantly associated with gestational age at birth. Receiver operator characteristic curves demonstrated improved prediction of delivery prior to 34 weeks at UCA 3=108^o (97% sensitivity, 65% specificity) compared to a cervical length of 25 mm. At <28 weeks, optimal performance of UCA 3 was found at 112^o (100% sensitivity, 62% specificity) compared with cervical length of 25 mm (29% sensitivity, 39% specificity). Binary logistic regression revealed UCA 3>108^o conferred an OR 35.1 (95% CI 7.7 to 160.3) for delivery prior to 34 weeks, and UCA 3>112^o an OR 42.0 (95% CI 5.3 to 332.1) for delivery prior to 28 weeks. In comparison, CL<25 mm had an OR 4.7 (95% CI 1.8 to 12.2) for delivery prior to 34 weeks and OR 6.0 (95% CI 1.9 to 19.3) prior to 28 weeks.

CONCLUSIONS

In patients with transvaginal cerclage, an increasingly obtuse anterior uterocervical angle reflects an increased risk of cerclage failure in the mid-trimester. Utilization of UCA measurement as a surveillance tool may improve identification of patients at risk for cerclage failure.