No. 373-Cervical Insufficiency and Cervical Cerclage

Application value of ultrasound elastography for screening of early pregnancy cervical insufficiency: a retrospective case-control study

OBJECTIVE

This study aimed to investigate changes in the cervical strain rate (SR), cervical length (CL), and uterine artery blood flow parameters during early pregnancy in women with cervical insufficiency and evaluate the clinical efficacy of these markers for screening of cervical insufficiency in early pregnancy.

METHODS

This retrospective study in 60 pregnant women with cervical insufficiency and 100 normal pregnant women was conducted between September 2021 and January 2023 and measured ultrasound parameters of the cervix during early pregnancy. The cervical SR, CL, and uterine artery resistance index (RI) were measured in both groups at 11-14 weeks of gestation. Strain elastography represented by the SR was used to assess the hardness of the internal and external cervical openings.

RESULTS

During early pregnancy, the SR at the internal and external cervical openings were significantly higher in the cervical insufficiency group than those in the normal pregnancy group (SR I: 0.19 ± 0.018% vs. 0.16 ± 0.014%; SR E: 0.26 ± 0.028% vs. 0.24 ± 0.025%; p < .001). The CL was significantly shorter in the cervical insufficiency group than that measured in the normal pregnancy group (34.3 ± 2.9 mm vs. 35.2 ± 1.99 mm; p = .036), while cervical blood perfusion was also poorer in the cervical insufficiency group than that in the normal pregnancy group (uterine artery RI: 0.76 ± 0.07 vs. 0.74 ± 0.05; p = .048). Receiver operating characteristic (ROC) curve analysis showed that the optimal critical values for diagnosing cervical insufficiency were 0.17% for SR I, 0.25% for SR E, 33.8 mm for CL, and 0.78 for uterine artery RI. Of these parameters, the ROC curve for SR I had the largest area under the curve [AUC = 0.89 (p < .001)], with the highest sensitivity (78%) and specificity (82%). Multivariate logistic regression analysis demonstrated that the SR at the internal cervical opening (OR 17.47, 95% confidence interval (CI) 5.08-60.08; p < .001) and CL (OR 5.05, 95% CI 1.66-15.32; p = .004) still showed significant differences between the two groups.

CONCLUSION

Cervical elastography is an effective tool for screening early pregnancy cervical insufficiency. The SR at the internal cervical opening is a valuable indicator for screening cervical insufficiency and has superior clinical efficacy for screening for this condition compared to that of CL and the uterine artery blood flow index.

A comparison of Mersilene tape versus braided suture in transvaginal cervical cerclage: A retrospective case-control study

OBJECTIVE

Previous studies have indicated that there is an association between cervical cerclage and type of suture material. However, it is still unclear which suture material can provide the greatest benefit to patients who have undergone cerclage. This study investigated the effect of two different suture materials (Mersilene tape vs braided suture) used for transvaginal cervical cerclage placement on maternal outcomes of women with cervical insufficiency.

METHODS

In this retrospective case-control study, 170 women who underwent history-, ultrasound-, or physical examination-indicated transvaginal cervical cerclage were categorized according to suture materials used for cerclage: a total of 96 received Mersilene tape and 74 received braided suture. Study participants received a transvaginal cervical cerclage before 28 weeks and were followed up until delivery to assess pregnancy and neonatal outcomes. The primary outcome was gestational age at delivery. Secondary outcomes included preterm premature rupture of membranes (PPROM), premature rupture of membranes (PROM), chorioamnionitis, neonatal survival rate, and neonatal morbidity.

RESULTS

Out of 170 eligible women, 74 (43.5%) received braided suture while 96 (56.5%) received Mersilene tape. Baseline characteristics were similar between the two groups. The group that received braided suture had a lower incidence of gestational age at delivery <37 weeks (29.2% vs 54.2%, P = 0.046), PPROM (9.5% vs 21.9%, P = 0.029) and PROM (17.6% vs 32.3%, P = 0.028) compared to the group that received Mersilene tape. However, there were no significant differences between the two groups in average gestational age at delivery, the rate of gestational age at delivery <24, <28, <32, and < 34 weeks, chorioamnionitis, and neonatal survival rate, as well as neonatal morbidity.

CONCLUSION

Compared to Mersilene tape, the utilization of braided suture has been significantly associated with a reduction in the incidence of gestational age at delivery <37 weeks, as well as a decreased risk of PPROM and PROM. However, the use of braided sutures did not result in discernible differences in the rates of chorioamnionitis or adverse neonatal outcomes.

Rate of preterm delivery and latency period in asymptomatic patients undergoing cerclage for very short cervix ≤10.0 mm

BACKGROUND

In asymptomatic women with cervical length ≤10 mm, vaginal progesterone has a limited effect in reducing the rate of preterm delivery.

OBJECTIVE

This study aimed to estimate the rate of preterm delivery and mean latency period to delivery in asymptomatic women with no history of preterm delivery and a cervical length of ≤10.0 mm undergoing or not undergoing cerclage and who were not treated with vaginal progesterone.

STUDY DESIGN

This was a retrospective analysis of asymptomatic patients with singleton pregnancies and no history of preterm delivery with an incidental finding of a cervical length of ≤10.0 mm measured by transvaginal ultrasound during midtrimester scan. Of note, 56 patients (63.6%) underwent cerclage placement and 32 patients (36.4%) did not, none of them received vaginal progesterone. Patients with evidence of advanced dilation, prolapsing membranes, ruptured membranes, or positive signs of infection were not candidates for cerclage placement and were excluded from the analysis. Differences in the prevalence of preterm delivery, mean gestational age at delivery, and mean latency from very short cervix identification to delivery between the 2 groups were calculated. Associations between cerclage and preterm delivery adjusted for maternal characteristics and fetal weight were estimated.

RESULTS

The median gestational ages at the time of cervical length measurement were 20 6/7 weeks (interquartile range, 17 5/7 to 23 3/7) in the cerclage group and 21 5/7 weeks (interquartile range, 17 6/7 to 23 6/7) in the no-cerclage group (P=.02). No difference in cervical length was observed between patients who had a cerclage (5.9±3.1 mm) and those who did not have a cerclage (6.5±3.2 mm) (P=.4). The prevalence of preterm delivery in women with cerclage vs women without cerclage was as follows: PTD at <37 weeks of gestation (31/56 [55.3%] in the cerclage group vs 28/32 [87.5%] in the no-cerclage group; adjusted odds ratio, 0.17; 95% confidence interval, 0.05-0.62; P=.008), PTD at ≤34 weeks of gestation (27/56 [48.2%] in the cerclage group vs 24/32 [75.0%] in the no-cerclage group; adjusted odds ratio, 0.16; 95% confidence interval, 0.05-0.55; P=.02), and PTD at ≤28 weeks of gestation (19/56 [33.9%] in the cerclage group vs 22/32 [68.7%] in the no-cerclage group; adjusted odds ratio, 0.15; 95% confidence interval, 0.05-0.51; P=.002). The median gestational ages at delivery were 32 6/7 weeks (interquartile range, 19 1/7 to 40 1/7) in the cerclage group and 28 1/7 weeks (interquartile range, 20 1/7 to 40 2/7) in the no-cerclage group (P=.001). The median latencies from the time of cervical length measurement to delivery were 84 days (interquartile range, 8-144) in the cerclage group and 43 days (interquartile range, 1-146) in the no-cerclage group (P=.003).

CONCLUSION

Among low-risk asymptomatic women with a very short cervix (≤10.0 mm) in the midtrimester of pregnancy, women treated with cerclage have an increased latency to delivery and a lower prevalence of preterm delivery than those treated with expectant management.

Prediction model for spontaneous preterm birth less than 32 weeks of gestation in low-risk women with mid-trimester short cervical length: a retrospective cohort study

BACKGROUND

A short cervix in mid-trimester pregnancy is a risk factor for spontaneous preterm birth. However, there is currently a lack of predictive models and classification systems for predicting spontaneous preterm birth in these patients, especially those without additional risk factors for spontaneous preterm birth.

METHODS

A retrospective observational cohort study of low-risk singleton pregnant women with a short cervix (≤ 25 mm) measured by transvaginal ultrasonography between 22 and 24 weeks was conducted. A multivariate logistic regression model for spontaneous preterm birth < 32 weeks in low-risk pregnant women with a short cervix was constructed. Moreover, we developed a nomogram to visualize the prediction model and stratified patients into three risk groups (low-, intermediate-, and high-risk groups) based on the total score obtained from the nomogram model.

RESULTS

Between 2020 and 2022, 213 low-risk women with a short cervix in mid-trimester pregnancy were enrolled in the study. Univariate logistic analysis revealed that a high body mass index, a history of three or more miscarriages, multiparity, a short cervical length, leukocytosis, and an elevated C-reactive protein level were associated with spontaneous preterm birth < 32 weeks, but multivariate analysis revealed that multiparity (OR, 3.31; 95% CI, 1.13-9.68), leukocytosis (OR, 3.96; 95% CI, 1.24-12.61) and a short cervical length (OR, 0.88; 95% CI, 0.82-0.94) were independent predictors of sPTB < 32 weeks. The model incorporating these three predictors displayed good discrimination and calibration, and the area under the ROC curve of this model was as high as 0.815 (95% CI, 0.700-0.931). Patients were stratified into low- (195 patients), intermediate- (14 patients) and high-risk (4 patients) groups according to the model, corresponding to patients with scores ≤ 120, 121-146, and > 146, respectively. The predicted probabilities of spontaneous preterm birth < 32 weeks for these groups were 6.38, 40.62, and 71.88%, respectively.

CONCLUSIONS

A noninvasive and efficient model to predict the occurrence of spontaneous preterm birth < 32 weeks in low-risk singleton pregnant women with a short cervix and a classification system were constructed in this study and can provide insight into the optimal management strategy for patients with different risk stratifications according to the score chart.

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.

Prediction and prevention of preterm birth: Quality assessment and systematic review of clinical practice guidelines using the AGREE II framework

BACKGROUND

Prediction of pregnancies at risk of preterm birth (PTB) may allow targeted prevention strategies.

OBJECTIVES

To assess quality of clinical practice guidelines (CPGs) and identify areas of agreement and contention in prediction and prevention of spontaneous PTB.

SEARCH STRATEGY

We searched for CPGs regarding PTB prediction and prevention in asymptomatic singleton pregnancies without language restriction in January 2024.

SELECTION CRITERIA

CPGs included were published between July 2017 and December 2023 and contained statements intended to direct clinical practice.

DATA COLLECTION AND ANALYSIS

CPG quality was assessed using the AGREE-II tool. Recommendations were extracted and grouped under domains of prediction and prevention, in general populations and high-risk groups.

MAIN RESULTS

We included 37 CPGs from 20 organizations; all were of moderate or high quality overall. There was consensus in prediction of PTB by identification of risk factors and cervical length screening in high-risk pregnancies and prevention of PTB by universal screening and treatment for asymptomatic bacteriuria, screening and treatment for BV in high-risk pregnancies, and use of preventative progesterone and cerclage. Areas of contention or limited consensus were the role of PTB clinics, universal cervical length measurement, biomarkers and cervical pessaries.

CONCLUSIONS

This review identified strengths and limitations of current PTB CPGs, and areas for future research.

Interventions for women with premature cervical dilatation and exposed fetal membranes to prevent pregnancy loss and preterm birth - A systematic review and meta-analysis

INTRODUCTION

The management of women with premature cervical dilatation and exposed unruptured fetal membranes remains uncertain and controversial. Treatment options may include expectant management or emergency cervical cerclage (ECC). Little is known regarding the effectiveness of individual interventions, or additional therapies. This systematic review aims to summarise all existing evidence to improve understanding of the treatment options and pregnancy outcomes for women presenting with premature cervical dilatation.

METHODS

Databases were searched using a prospective protocol (CRD42021286275). Studies were eligible for inclusion across five distinct comparison groups if they included women with premature cervical dilatation and reported clinical outcomes. Primary outcome was pregnancy loss (miscarriage, stillbirth, neonatal death and termination of pregnancy). Planned subgroups included singletons and twins, and low-cervical or high-cervical suture. Pairwise random effects meta-analysis calculated in RevMan5.4, single arm random effects proportional meta-analysis calculated using RevMan and R studio. Risk of bias was assessed using Cochrane Risk of Bias tool and Joanna Briggs Institute checklists.

RESULTS

6781 abstracts were screened, and 177 (four randomised controlled trials) studies included in the five analysis groups. Women receiving ECC were significantly less likely to experience pregnancy loss (combined RR 0.48 95 %CI 0.39-0.59 singleton RR 0.48 95 %CI 0.34-0.67 twin only RR 0.39 95 %CI 0.26-0.58) compared to expectant management. Adjuvant amnioreduction with ECC was not found to reduce pregnancy loss (RR 1.12 (95 % CI 0.73-1.72) or any other outcomes compared to ECC without amnioreduction. Women were significantly more likely to experience pregnancy loss (RR3.85 95 %CI 3.13-4.74) after ECC compared to planned cerclage. The probability of intra-operative rupture of membranes at ECC insertion was 3.3 % (95 %CI 1.8-5.1) and the probability of an ECC attempt being abandoned was 2.6 % (95 %CI 1.1-4.6 %).

DISCUSSION

ECC appears to reduce the risk of pregnancy loss for both singletons and twins although the overall quality of evidence is poor. It is important that women are counselled regarding the outcomes following cerclage according to indication. Pregnancy complications are common after ECC although the rates of intra-operative complications are lower than may be anticipated. Randomised trials remain imperative for understanding the role of ECC and adjunctive treatments in preventing pregnancy loss in this condition.

Development and validation of a nomogram for individualized prediction of spontaneous extremely preterm birth at < 28 weeks in twin pregnancy: a retrospective cohort study

PURPOSE

To develop a nomogram to predict spontaneous preterm birth at < 28 weeks in pregnant women with twin pregnancies.

METHODS

We retrospectively studied the medical records of twin-pregnancy women with asymptomatic cervical dilation or cervical shortening between December 2015 to February 2022 in two hospitals. Data from one center was used to develop the model and data from the other was used to evaluate the model.

RESULTS

A total of 270 twin pregnancies were enrolled in the study. We incorporated 4 items (cervical length, cervical dilation, C-reactive protein and the use of cerclage) to build the 28-week nomogram with satisfactory discrimination and calibration when applied to the validation sets. The C index for the 28-week nomogram in the development and external cohort was 0.88 (95% CI, 0.84-0.93) and 0.89 (95% CI, 0.80-0.98), respectively. The nomogram reached a sensitivity of 70.70%, specificity of 97.10%, positive predicted value of 95.61% and negative predicted value of 78.77%. Moreover, the decision curve analysis indicated that the nomogram showed positive clinical benefit.

CONCLUSION

We developed and validated a nomogram with good performance in predicting individual risk of spontaneous preterm birth at < 28 in twin pregnancy.

Nomogram-based risk assessment for emergency cervical cerclage failure in patients with cervical insufficiency

Background

Cervical insufficiency can lead to preterm birth and neonatal mortality. Emergency cervical cerclage is a surgical intervention aimed at preventing preterm birth in patients with cervical insufficiency. However, some patients may experience cerclage failure. This study aimed to identify the risk factors associated with cerclage failure and develop a predictive nomogram model for patients with cervical insufficiency undergoing emergency cervical cerclage.

Methods

Data of 200 patients who underwent emergency cervical cerclage for cervical insufficiency were retrospectively analyzed. Patients were categorized into successful and failed groups based on their ability to take the infant home. Univariate and multivariate logistic regression analyses were performed to identify risk factors for cerclage failure. A nomogram model was developed based on multivariate logistic regression results, and its performance was assessed using receiver operating characteristic curves, calibration plots, and decision curve analysis (DCA).

Results

Univariate logistic regression analysis identified 11 potential risk factors for cerclage failure, including the presence of polycystic ovary syndrome (PCOS), vaginitis, cervical dilation, preoperative C-reactive protein, routine vaginal lavage after cervical cerclage, delivery, gestational age, extended days, chorioamnionitis, intrauterine infection, cervical laceration, and premature rupture of membranes. Multivariate logistic regression analysis revealed that PCOS, cervical dilation after cervical cerclage were independent risk factors for cerclage failure while routine vaginal lavage was a protective factor against failure. The nomogram predictive model demonstrated an area under the curve value of 0.975, indicating excellent discriminatory ability. The calibration plot showed good consistency between the nomogram predictions and actual observations. DCA demonstrated the strong clinical applicability of the nomogram.

Conclusions

This study successfully identified risk factors associated with emergency cervical cerclage failure in patients with cervical insufficiency and developed a predictive nomogram model. This model can assist clinicians in making informed decisions and accurately predicting the risk of cerclage failure in these patients.

Perinatal Outcomes Associated With the Modified Shirodkar Cervical Cerclage Technique

OBJECTIVE

The objective of this study was to describe demographic and clinical characteristics and surgical and neonatal results related to the modified Shirodkar cervical cerclage technique.

MATERIALS AND METHODS

This was an observational descriptive and retrospective study. Data was called from anonymized medical records of women who were pregnant and diagnosed with cervical incompetence and who had also undergone cervical cerclage procedures using the modified Shirodkar technique. The variables recorded included demographics such as the maternal age of patients, clinical features like obstetric history, physical examination, and ultrasound findings, and surgical and neonatal outcomes. The qualitative variables were processed using frequencies and percentages, and the quantitative variables were obtained through median, interquartile range, mean, and standard deviation.

RESULTS

Our study included 39 anonymized medical records. The main indication for cervical cerclage placement was prophylactic (56%). The median gestational age at cerclage placement was 16 weeks, with a median gestational age at birth of 38 weeks; only 13% had complications related to prematurity, and 5% were admitted to the neonatal intensive care unit.

CONCLUSION

The modified Shirodkar technique is associated with favorable surgical, maternal, and neonatal outcomes.

Early Magnetic Resonance Imaging Measurements and Prediction of Second Trimester Pregnancy Loss: a Nomogram Model Analysis

Objective

To investigate the magnetic resonance imaging (MRI) features of women with prior second-trimester pregnancy loss, and to establish a nomogram prediction model for subsequent miscarriage.

Methods

A retrospective cohort study of women with prior second-trimester pregnancy loss from January 2018 to December 2021 in Second Affiliated Hospital of Soochow University was performed. A total of 245 patients were included. Data from January 2018 to December 2019 were used to construct the model, and data from January 2020 to December 2021 were used to evaluate the model. Data on maternal demographic characteristics, MRI cervical measurements were extracted. The prediction model was constructed with independent variables determined by multivariate logistic regression analyses. Through receiver-operating characteristic (ROC) curve analysis, the predictive ability of the model for subsequent second trimester pregnancy loss in women was evaluated, and internal validation was performed through validation data.

Results

Thin cervix was observed in 77 (31.42%) women with prior second-trimester pregnancy loss, the mean longitudinal diameter of cervical canal on MRI was 11.76±2.75mm. The model reached a sensitivity of 80%, specificity of 75.90%, positive predictive value (PPV) of 55.80% and negative predictive value of 90.90%; ROC characteristics proved that the model was superior to any single parameter with an AUC of 0.826.

Conclusion

Our observations showed that thin cervix and longitudinal diameter of cervical canal reliably predicted second trimester pregnancy loss. We developed and validated a nomogram model to predict the individual probability of second trimester pregnancy loss in the next pregnancy and hopefully improve the prediction and indication of interventions.

Perinatal outcomes in patients undergoing repeat cerclage: A retrospective case series study

OBJECTIVE

This study aimed to describe the pregnancy outcomes of a case series of patients with probable cerclage failure who received repeat cerclage (RC) with potential indications.

METHODS

We retrospectively collected a case series of 55 singleton pregnancies with RC from 2019 to 2022 in Shanghai, China. All included women provided written informed consent, and the study was approved by the ethics committees of the two hospitals. We compared pregnancy outcomes between pregnancies with RC for different indications.

RESULTS

Among the case series, nine patients underwent RC for the indication of protruding membranes below the previous suture loop (group A), and the other 46 patients for painless cervix dilation (group B). Gestational age at delivery was shorter in group B than in group A (30.7 vs 37.6 weeks, P = 0.009). Rates of preterm birth <32 weeks (63.0% vs 22.2%, P = 0.033) and < 37 weeks (76.1% vs 33.3%, P = 0.002) were significantly higher in group B than in group A. Of the 46 patients who underwent RC for painless cervical dilation, 28 had cervical dilation of 1 to 2 cm (group C) and the other 18 had cervical dilation of 3 to 6 cm (group D). The gestational age at delivery was shorter in group D than in group C (27.4 vs 31.5 weeks, P = 0.037). However, rates of preterm birth <32 or <37 weeks were similar between the groups.

CONCLUSION

RC may constitute a rescue strategy for patients with probable cerclage failure. Protrusion of membranes below the cerclage loop or cervical dilation <3 cm may be an indicator of better pregnancy outcome.

Risk factors for high-stage histological chorioamnionitis among pregnancies with cervical incompetence

AIM

The study aimed to identify predictive risk factor to identify high-stage histological chorioamnionitis (HCA) in pregnancies with cervical incompetence (CIC).

METHODS

A retrospective cohort study was conducted by including 116 pregnant women with cervical incompetence that required prophylactical and therapeutical cerclage. The histopathology examination on placenta was conducted with informed patient consent. All the cases included in this study were divided based on the severity degree of HCA. The demographic characteristic and the parameters related to maternal and fetal outcome were all analyzed. Besides, perioperative parameters of cerclage, including cervical length, cervical morphology, and laboratory indexes were also compared between two groups. Univariate and multivariate logistic regression analysis were used to determine the risk factor of severe chorioamnionitis.

RESULTS

Severe HCA was significantly associated with cervical morphology, cerclage indication, cerclage type, and cervical length measured via ultrasound and vaginal examination. After adjusted for confounders, V-type funneling and short cervix was indicated as independent risk factors of severe HCA by multivariate logistic regression analysis, respectively.

CONCLUSIONS

V-type funneling and short cervix may indicate the elevated risk of high-stage HCA. Due to the negative outcomes related with high-stage HCA, appropriate prenatal treatment would improve the pregnancy outcomes in cerclaged population. To facilitate postpartum treatment, placental histological examination should be routinely recommended to identify the high-stage HCA, especially in high risk pregnancies.

Vaginal delivery of triplets after emergency transvaginal cerclage: A case report and literature review

RATIONALE

To report a peculiar case of vaginal delivery of a triplet after emergency transvaginal cerclage and to find a way to optimize some extreme situations encountered in clinical practice after evaluating feasibility.

PATIENT CONCERNS

A 33-year-old gravida 6, para 0050 woman at 21 + 6 weeks of gestation was referred to the obstetric department for opening of the cervical canal. An emergency McDonald cerclage was performed at 22 weeks of gestation after a comprehensive assessment, and the pregnancy ended with vaginal delivery at 24 + 6 weeks of gestation. The postpartum period was normal, and the newborns were discharged to home care after treatment in the neonatal intensive care unit.

INTERVENTIONS

After discussing the risks, the patient requested emergency transvaginal McDonald cerclage at 22 weeks of gestation.

OUTCOMES

Emergency McDonald cerclage was performed at 22 weeks of gestation, and the pregnancy ended with vaginal delivery at 24 + 6/25 weeks of gestation, successfully prolonging gestation by 20/21 days. The postpartum period had no exceptional circumstances, and newborns were discharged to home care after treatment in the neonatal intensive care unit for 104/98/104 days.

LESSONS

Emergency cerclage seems to be impossible in multiple pregnancies. However, in this case, after a comprehensive assessment, it was feasible to extend the gestational age by emergency cerclage, and prompt and accurate evaluation is important to avoid complications and individualize the following management. In this case, we may find a way to optimize some extreme situations encountered in clinical practice and offer a glimmer of hope for families challenged with multiple pregnancies at risk of preterm delivery. However, more high-quality studies are needed to prove the effectiveness and safety of emergency cerclages in triplets.

Comparison of two emergency cervical cerclage techniques in twin pregnancies: A retrospective cohort study matched with cervical dilation

OBJECTIVES

This retrospective cohort study aimed to assess the efficacy of emergency cervical cerclage (ECC) performed with the combined McDonald-Shirodkar technique in twin pregnancies between 18 and 26 weeks of pregnancy with painless cervical dilation 1 to 6 cm.

METHODS

A retrospective cohort study matched with the degree of cervical dilation was conducted. The study group (case group) included women with twin pregnancies undergoing combined McDonald-Shirodkar approach with cervical dilation ≥1 cm between 18 to 26 weeks of gestation at four institutions, from December 2015 to December 2022. To minimize confounding factors, we elucidated the causality structure using a directed acyclic graph and performed 1:1 case-control matching. A control group underwent the McDonald approach. The primary outcome was gestational age (GA) at delivery. The secondary outcomes were pregnancy latency; the rates of spontaneous preterm birth at <28, <30, <32, and <34 weeks; and neonatal outcomes. Additional subanalysis was performed by dividing the patients into two subgroups of women with cervical dilation ≥3 cm and <3 cm.

RESULTS

A total of 84 twin pregnancies were managed with either the combined McDonald-Shirodkar approach (case group: n = 42) or the McDonald approach (control group: n = 42). Demographic characteristics were not significantly different in the two groups (P > 0.05). After adjusting for confounders that were represented by a directed acyclic graph, median GA at delivery was significantly higher (30.5 vs 27 weeks; Bate: 3.40 [95% confidence interval (CI), 2.13-4.67], P < 0.001) and median pregnancy latency was significantly longer (56 vs 28 days; Bate: 24.04 [95% CI, 13.31-34.78], P < 0.001) in the case group compared with the control group. Rates of spontaneous preterm birth at <28, <30, <32, and <34 weeks were significantly lower in the case group than in the control group. For neonatal outcomes, there was higher birth weight (1543.75 vs 980 g; Bate: 420.08 [95% CI, 192.18-647.98], P < 0.001) and significantly lower overall perinatal mortality (7.1% vs 31%; adjusted odds ratio, 0.16 [95% CI, 0.04-0.70], P = 0.014) in the case group compared with the control group. When cervical dilation was ≥3 cm, the combined McDonald-Shirodkar procedure can significantly reduce perinatal mortality (8.3% vs 46.7%; adjusted odds ratio, 0.09 [95% CI, 0.01-0.77], P = 0.028), significantly decrease the risk of delivery at <28 and <30 weeks, and prolong GA at delivery and pregnancy latency compared with the McDonald procedure.

CONCLUSIONS

ECC performed with the combined McDonald-Shirodkar procedure in women with twin pregnancies who have cervical dilation 1 to 6 cm in midtrimester pregnancy may reduce the rate of spontaneous preterm birth and improve perinatal and neonatal outcomes compared with the McDonald procedure, especially for twin pregnancies in women with cervical dilation of 3 to 6 cm and prolapsed membranes.

Transvaginal cerclage for prevention of preterm birth in twin pregnancies with cervical dilatation or shortening: A prospective observational study

OBJECTIVE

To investigate the efficacy of transvaginal cerclage in twin pregnancies with cervical shortening, and to narrow the threshold cervical length for transvaginal cerclage.

METHODS

This is a prospective cohort study and 177 twin pregnancies with asymptomatic cervical dilatation or cervical length of 15 mm or less between 16+0 and 25+6 weeks of pregnancy were included. Patients independently chose either transvaginal cerclage (n = 129) or no cerclage treatment (n = 48) after being consulted on the risk and potential benefit of transvaginal cerclage. The primary outcome measures were gestational age at delivery and neonatal survival rate.

RESULTS

Compared with the no cerclage group, the cerclage group exhibited a higher gestational age at delivery (32.1 ± 4.5 vs 28.3 ± 6.2 weeks, P < 0.001) and a higher neonatal survival rate (86.4% vs 47.9%, P < 0.001). Subgroup analysis showed that in twin pregnancies with cervical dilatation or cervical length less than 10 mm, the cerclage group had significantly higher gestational age at delivery (31.3 ± 4.6 vs 23.4 ± 4.3 weeks, P < 0.001) and a higher neonatal survival rate (123 [85.4%] vs 4 [9.1%], P < 0.001) than the no cerclage group, but in twins when cervical length was 10-15 mm, the two measures were similar between the two groups.

CONCLUSION

Transvaginal cerclage may provide benefits for twins when cervical dilatation or cervical length is less than 10 mm, but its efficacy might not extend to twins when the cervical length is 10-15 mm. Further evidence is needed to confirm the efficacy of transvaginal cerclage for twin pregnancies with a short cervix.

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.

Are Cervical Pessaries Effective in Preventing Preterm Birth?

Preterm births are a significant concern, as they can have serious consequences for both infants and mothers. It is crucial to identify risk factors associated with preterm birth and to implement effective interventions, such as progesterone, cervical pessary, and cervical cerclage, to prevent it. This systematic review aims to evaluate the efficacy of cervical pessary in reducing spontaneous preterm delivery. However, cervical pessaries have limited research and conflicting findings when compared to other interventions for preventing preterm labor. Therefore, this review seeks to analyze various studies to evaluate their overall effectiveness and better understand their role in treating this vulnerable population. The literature search was conducted using PubMed between January and September 2023, and the systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The results of this review highlight the importance of continued research into mitigation strategies for preterm birth. There is some evidence that indicates that using cervical pessaries before 34 weeks can be effective. While some studies have reported positive outcomes when cervical pessaries are combined with other treatments like progesterone, there is no solid statistical evidence to support this claim. Furthermore, additional research is needed to comprehend the impact of singleton pregnancies and long-term outcomes for both mothers and infants.

Efficacy of emergency cervical cerclage in twin pregnancies and factors affecting the clinical effects of emergency cerclage

OBJECTIVES

To estimate clinical effects of emergency cervical cerclage in twin pregnancies with cervical dilation ≥1.0 cm in mid-trimester of gestation and to identify risk factors after cerclage.

METHODS

This retrospective cohort study included 99 twin pregnancies with cervical dilation ≥1cm in the mid-trimester of gestation at three institutions, from December 2015 through December 2021. The cases were treated with emergency cervical cerclage (52 cases) or expectant management (47 cases). Compare the pregnancy and neonatal outcomes of the two groups. Multiple logistic regression analysis was used to determine the independent risk factors associated with cerclage.

RESULTS

Cerclage placement was associated with significantly longer gestation age and prolongation of the gestational latency (p < .05). In the cases, compared to expectant treatments, spontaneous preterm birth (sPTB) at <26, <28, <30, <32 weeks was significantly less frequent (p < .05). Pre-operation WBC > 11.55 × 10⁹/L, CRP > 10.1 and cervical dilation >3.5 cm were found to be independent risk factors for delivery 28 weeks after cerclage.

CONCLUSIONS

Cervical cerclage in twin pregnancies with cervical dilation ≥1.0 cm in mid-trimester of gestation may prolong pregnancy and gestation age, and improve pregnancy and neonatal outcomes compared with expectant management. The strongest predictor of sPTB before 28 weeks after ECC were pre-operation WBC >11.55 × 10^9/L, CRP > 10.1 and cervical dilation >3.5 cm.

Value of post-cerclage transvaginal ultrasound in predicting preterm birth at <28 weeks in twin pregnancy with ultrasound-indicated cerclage

OBJECTIVE

To evaluate the value of transvaginal ultrasound parameters before and after cerclage in twins in predicting spontaneous preterm birth (sPTB) before 28+0 weeks.

METHODS

We retrospectively studied the medical records of twin-pregnant women who underwent ultrasound-indicated cerclage between January 2016 and February 2022 at our hospital. Recorded transvaginal ultrasound images before and after cerclage were reassessed for cervical length (CL), uterocervical angle (UCA), funneling, and sludge. Multivariate logistic and Cox regression analyses were performed to identify the independent risk factors associated with sPTB before 28 weeks.

RESULTS

A total of 69 women were included. Among them, 17 women (24.64%) delivered before 28 weeks of age. Regression analysis revealed a significant association of post-cerclage CL, UCA, white blood cell (WBC) count, and gestational age (GA) at cerclage with sPTB before 28 weeks. The area under the curve of these predictors was 0.938 (95% confidence interval, 0.882-0.994; p < .001), with a sensitivity of 88.2%, specificity of 92.3%, positive predictive value of 78.9%, and negative predictive value of 96.0%. Cox analysis showed that post-cerclage UCA was an independent risk factor affecting the cerclage-to-delivery interval (hazard ratios, 1.026; 95% confidence interval (CI), 1.004-1.048; p = .019).

CONCLUSIONS

The combination of post-cerclage CL, UCA, WBC count, and GA at cerclage showed good performance in predicting sPTB at <28 weeks in twin pregnancy. Post-cerclage UCA is also associated with pregnancy latency. We found that post-cerclage cervical ultrasound may be useful to predict preterm birth before 28 weeks in twins who undergo ultrasound-indicated cerclage.

Factors Associated with Spontaneous Preterm Birth after Ultrasound-Indicated Cerclage

Ultrasound-indicated cerclage (UIC) is recommended to prevent spontaneous preterm birth (sPTB) in women with a short cervix at mid-trimester and a history of PTB. We assessed the factors related to sPTB after UIC and determined the corresponding risks. This retrospective cohort study was conducted at a university hospital. UIC was performed between 15 and 26 weeks of gestation in women with a cervical length of <2.5 cm. Univariate and multivariate analyses were used to examine factors associated with sPTB after UIC. An earlier gestational age and shorter cervical length at UIC were associated with sPTB after UIC. While PTB history was not associated with an increased risk of sPTB, it did increase the risk of repeat cerclage after UIC. Higher levels of preoperative serum inflammatory markers and obesity significantly increased the risk of sPTB after UIC. These findings provide helpful guidance for patient counseling and management in predicting the delivery timing after UIC in women with a short cervix in the mid-trimester.

National and international guidelines on the management of twin pregnancies: a comparative review

Twin gestations are associated with increased risk of pregnancy complications. However, high-quality evidence regarding the management of twin pregnancies is limited, often resulting in inconsistencies in the recommendations of various national and international professional societies. In addition, some recommendations related to the management of twin gestations are often missing from the clinical guidelines dedicated to twin pregnancies and are instead included in the practice guidelines on specific pregnancy complications (eg, preterm birth) of the same professional society. This can make it challenging for care providers to easily identify and compare recommendations for the management of twin pregnancies. This study aimed to identify, summarize, and compare the recommendations of selected professional societies from high-income countries on the management of twin pregnancies, highlighting areas of both consensus and controversy. We reviewed clinical practice guidelines of selected major professional societies that were either specific to twin pregnancies or were focused on pregnancy complications or aspects of antenatal care that may be relevant for twin pregnancies. We decided a priori to include clinical guidelines from 7 high-income countries (United States, Canada, United Kingdom, France, Germany, and Australia and New Zealand grouped together) and from 2 international societies (International Society of Ultrasound in Obstetrics and Gynecology and the International Federation of Gynecology and Obstetrics). We identified recommendations regarding the following care areas: first-trimester care, antenatal surveillance, preterm birth and other pregnancy complications (preeclampsia, fetal growth restriction, and gestational diabetes mellitus), and timing and mode of delivery. We identified 28 guidelines published by 11 professional societies from the 7 countries and 2 international societies. Thirteen of these guidelines focus on twin pregnancies, whereas the other 16 focus on specific pregnancy complications predominantly in singletons but also include some recommendations for twin pregnancies. Most of the guidelines are recent, with 15 of the 29 guidelines published over the past 3 years. We identified considerable disagreement among guidelines, primarily in 4 key areas: screening and prevention of preterm birth, using aspirin to prevent preeclampsia, defining fetal growth restriction, and the timing of delivery. In addition, there is limited guidance on several important areas, including the implications of the "vanishing twin" phenomenon, technical aspects and risks of invasive procedures, nutrition and weight gain, physical and sexual activity, the optimal growth chart to be used in twin pregnancies, the diagnosis and management of gestational diabetes mellitus, and intrapartum care.This consolidation of key recommendations across several clinical practice guidelines can assist healthcare providers in accessing and comparing recommendations on the management of twin pregnancies and identifies high-priority areas for future research based on either continued disagreement among societies or limited current evidence to guide care.

The use of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation: a twelve-year retrospective cohort study

BACKGROUND

To identify the effect and optimal time of cervical cerclage in asymptomatic twin pregnancies with cervical shortening or dilation.

METHODS

This observational retrospective study enrolled all women with asymptomatic twin pregnancies who were diagnosed with asymptomatic cervical shortening or dilation at the Second Affiliated Hospital of Wenzhou Medical University between 2010 and 2022. Women included were allocated into the cerclage group (n = 36) and the no cerclage group (n = 22). The cerclage group was further divided into the cerclage group (< 24 weeks group) and the cerclage group (24-28 weeks group) according to the time of cerclage. The no cerclage group was further divided into no cerclage group (< 24 weeks group) and no cerclage group (24-28 weeks group) according to the time of ultrasound-indicated or physical exam indicated cerclage. The rates of PTB < 24, 28, 32 and 34 weeks of gestation, maternal and neonatal outcomes were compared among the groups.

RESULTS

The gestational age (GA) at delivery was higher (P = 0.005) and the interval time between the presentation of the indicated cerclage and delivery was longer in the cerclage group (P < 0.001). The rates of PTB before 28, 32, and 34 weeks of gestation, caesarean section and stillbirth were lower in the cerclage group (P < 0.05). The birthweight of the twins was higher in the cerclage group (P = 0.012). Admissions to the NICU were more frequent in pregnancies with no cerclage (P = 0.008). Subgroup analysis showed that the interval time between the presentation and delivery was longer in the cerclage group (< 24 weeks) (P < 0.001). The GA at delivery and the birthweight of the twins were significantly higher in the cerclage group (< 24 weeks) (P < 0.001). No differences were found in the GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight between the cerclage group (24-28 weeks group) and the control group (24-28 weeks group) (P > 0.05).

CONCLUSIONS

Cerclage appears to prolong the GA at delivery and the interval time between the presentation to delivery, and may reduce the incidence of PTB before 28, 32 and 34 weeks of gestation and adverse perinatal outcomes in asymptomatic twin pregnancies with cervical shortening or dilation. Cerclage before 24 weeks of gestation showed longer GA at delivery, longer interval time between the presentation to delivery and higher birthweight of the twins. The GA at presentation, the GA at delivery, the interval time between the presentation to delivery and birthweight in women with cerclage at 24-28 weeks were similar to those in women without cerclage at 24-28 weeks.

Role of body mass index in pregnancy outcomes after emergency cerclage for cervical insufficiency in singleton pregnant patients

BACKGROUND

The study aims were to analyze pregnancy outcomes after the use of emergency cerclage in patients with different BMIs.

METHODS

A total of 76 singleton pregnant patients who underwent emergency cerclage at a tertiary comprehensive hospital in China between Jan 2017 and Dec 2021 were retrospectively divided into an obesity group of 37 patients with BMIs ≥ 28 kg/m2 and a non-obesity group of 39 patients with BMIs < 28 kg/m2. The medical records of patients were reviewed and all relevant clinical data were further collected into an itemized data spreadsheet for various analyses.

RESULTS

Emergent cerclage, along with amnioreduction if needed, could be safely performed on both obese and non-obese pregnant women with a dilated external cervix (> 1 cm), which effectively prolonged the gestational week up to ≥ 25 weeks. Obese gravidae had shorter suture-to-delivery intervals and mean pregnancy lengths but more spontaneous preterm births before 37 weeks, and a lower live birth rate (P < 0.05). Logistic regression analysis revealed that BMI, how many times cerclages have been performed during pregnancy (frequency of cerclage) and bacterial vaginosis, aerobic vaginitis and vulvovaginal candidiasis (vaginal microecology) were significantly correlated with fetal loss (P < 0.05), while rank correlation analysis established a negative correlation between BMI values and the suture-to-delivery interval (P = 0.031).

CONCLUSIONS

Pregnant cervical insufficiency patients with BMIs > 28 kg/m2 may ill-serve the gestational outcomes and suture-to-delivery interval after their emergent cerclage. Additionally, BMI, frequency of cerclage and vaginal microecology accounted for higher fetal loss in patients who underwent emergency cerclage.

Cervical Cerclage: A Comprehensive Review of Major Guidelines

Importance

Cervical cerclage (CC) represents one of the few effective measures currently available for the prevention of preterm delivery caused by cervical insufficiency, thus contributing in the reduction of neonatal morbidity and mortality rates.

Objective

The aim of this study was to review and compare the most recently published major guidelines on the indications, contraindications, techniques, and timing of placing and removal of CC.

Evidence Acquisition

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the International Federation of Gynecology and Obstetrics (FIGO) on CC was carried out.

Results

There is a consensus among the reviewed guidelines regarding the recommended techniques, the indications for rescue CC, the contraindications, as well as the optimal timing of CC placement and removal. All medical societies also agree that ultrasound-indicated CC is justified in women with history of prior spontaneous PTD or mid-trimester miscarriage and a short cervical length detected on ultrasound. In addition, after CC, serial sonographic measurement of the cervical length, bed rest, and routine use of antibiotics, tocolysis, and progesterone are unanimously discouraged. In case of established preterm labor, CC should be removed, according to ACOG, RCOG, and SOGC. Furthermore, RCOG and SOGC agree on the prerequisites that should be met before attempting CC. These 2 guidelines along with FIGO recommend history-indicated CC for women with 3 or more previous preterm deliveries and/or second trimester pregnancy miscarriages, whereas the ACOG suggests the use of CC in singleton pregnancies with 1 or more previous second trimester miscarriages related to painless cervical dilation or prior CC due to painless cervical dilation in the second trimester. The role of amniocentesis in ruling out intra-amniotic infection before rescue CC remains a matter of debate.

Conclusions

Cervical cerclage is an obstetric intervention used to prevent miscarriage and preterm delivery in women considered as high-risk for these common pregnancy complications. The development of universal international practice protocols for the placement of CC seems of paramount importance and will hopefully improve the outcomes of such pregnancies.

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.

Amniotic Sludge and Prematurity: Systematic Review and Meta-analysis

OBJECTIVE

 To perform a systematic review and meta-analysis of studies on maternal, fetal, and neonatal outcomes of women with singleton pregnancies, after spontaneous conception, and with the diagnosis of amniotic sludge before 37 weeks of gestational age.

DATA SOURCES

 We conducted a search on the PubMed, Cochrane, Bireme, and Theses databases until June 2022.

SELECTION OF STUDIES

 Using the keywords intra-amniotic sludge or fluid sludge or echogenic particles, we found 263 articles, 132 of which were duplicates, and 70 were discarded because they did not meet the inclusion criteria.

DATA COLLECTION

 The articles retrieved were analyzed by 2 reviewers; 61 were selected for full-text analysis, 18 were included for a qualitative analysis, and 14, for a quantitative analysis.

DATA SYNTHESIS

 Among the maternal outcomes analyzed, there was an increased risk of preterm labor (95% confidence interval [95%CI]: 1.45-2.03), premature rupture of ovular membranes (95%CI: 1.99-3.79), and clinical (95%CI: 1.41-6.19) and histological chorioamnionitis (95%CI: 1.75-3.12). Regarding the fetal outcomes, there was a significant increase in the risk of morbidity (95%CI: 1.80-3.17), mortality (95%CI: 1.14-18.57), admission to the Neonatal Intensive Care Unit (NICU; 95%CI: 1.17-1.95), and neonatal sepsis (95%CI: 2.29-7.55).

CONCLUSION

 The results of the present study indicate that the presence of amniotic sludge is a risk marker for preterm delivery. Despite the heterogeneity of the studies analyzed, even in patients with other risk factors for prematurity, such as short cervix and previous preterm delivery, the presence of amniotic sludge increases the risk of premature labor. Moreover, antibiotic therapy seems to be a treatment for amniotic sludge, and it may prolong pregnancy.

Prior Spontaneous or Induced Abortion Is a Risk Factor for Cervical Dysfunction in Pregnant Women: a Systematic Review and Meta-analysis

A history of abortion is associated with cervical dysfunction during pregnancy, but there remains uncertainty about whether risk can be stratified by the abortion type, the abortion procedure, or number of previous abortions. The objective of this study was to verify the relationship between cervical dysfunction measures in pregnancies with and without a history of termination. Embase and Medline databases were searched from 01 January 1960 to 01 March 2022 resulting in a full-text review of 28 studies. The Newcastle-Ottawa Scale (NOS) was used to assess the quality and risk of bias for non-randomized studies. The meta-analysis consisted of 6 studies that met all inclusion and exclusion criteria and included a combined total of 2,513,044 pregnancies. Cervical dysfunction was defined as either cervical insufficiency/incompetence in 4 of the studies and as short cervix in the others. Results from a random-effects model using reported adjusted odds ratios (aOR) estimated an increase in the odds of 2.71 (95% CI 1.76, 4.16) for cervical dysfunction in the current pregnancy related to a history of induced or spontaneous abortion. Subgroup analyses with only induced abortions (surgical/medical) estimated an aOR of 2.54 (95% CI 1.41, 4.57), while studies limited to surgical abortions had an aOR of 4.08 (95% CI 2.84, 5.86). The risk of cervical dysfunction in the current pregnancy was also found to be dependent on the number of previous abortions. In this meta-analysis, a prior history of abortion, and specifically induced abortions, was associated with cervical dysfunction. The protocol was registered in PROSPERO (CRD42020209723).

Emergency cerclage using double-level versus single-level suture in the management of cervical insufficiency (Cervical Occlusion double-level Stitch Application, ): study protocol for a multicentre, non-blinded, randomised controlled trial

INTRODUCTION

Cervical insufficiency accounts for 15% of recurrent pregnancy losses between 16 and 28 weeks of gestation. The aim of the study is to verify the effectiveness of emergency double-level cerclage with vaginal progesterone in cervical insufficiency treatment in terms of the prevention of preterm delivery before 34 weeks of gestation.

METHODS AND ANALYSIS

This trial is a multicentre, non-blinded, randomised study with 1:1 allocation ratio. The study is conducted at tertiary perinatal care departments in Poland. It will include patients with cervical insufficiency with the fetal membranes visible in the open cervical canal or protruding into the vagina between 16+0 and 23+6 weeks of pregnancy. They will be randomised into two arms: emergency single-level cerclage with vaginal progesterone or double-level cerclage with vaginal progesterone. All will be administered antibiotics and indomethacin. The primary outcome is the rate of deliveries below 34+0 weeks of gestation, while secondary outcomes include gestational age at delivery, neonatal outcomes, maternal outcomes according to the Core Outcome Set for Evaluation of Interventions to Prevent Preterm Birth and cerclage procedure complications. The planned number of participants according to the power analysis is 78.

ETHICS AND DISSEMINATION

The study protocol was written in accordance with the Standard Protocol Items: Recommendations for Interventional Trials statement. It was created according to the requirements of the Declaration of Helsinki for Medical Research involving Human Subject. Ethical approval was obtained from the Ethics Committee of the Centre of Postgraduate Medical Education (no. 1/2022). The study protocol was approved and published by ClinicalTrials.gov (posted on 24 February 2022). All participants gave a written informed consent. After completion of the study its results will be published in a peer-reviewed English language journal.

TRIAL REGISTRATION

NCT05268640.

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.

Efficacy of ultrasound-indicated cerclage in twin pregnancies: a retrospective case-control study matched by cervical length

BACKGROUND

Twin pregnancies with a progressively shortening cervix in the midterm pregnancy have an increasing risk for spontaneous preterm birth. Currently, there is no known effective method to prevent preterm birth among those women, and the use of an ultrasound-indicated cerclage in twin pregnancies is still controversial.

OBJECTIVE

This study aimed to estimate whether a combination of ultrasound-indicated cerclage, indomethacin, and antibiotics in twin pregnancies between 18 and 26 weeks' gestation could extend the pregnancy, reduce the risk for spontaneous preterm birth, and improve perinatal and neonatal outcomes.

STUDY DESIGN

A retrospective cohort study was conducted. The ultrasound-indicated cerclage group included twin pregnancies with a transvaginal cervical length <25 mm that underwent cerclage at 18 to 26 weeks of gestation in the Women's Hospital, Zhejiang University School of Medicine, from December 2015 through August 2021. Twin pregnancies in our study that underwent cerclage also received antibiotics and indomethacin. A control group of twin pregnancies that were managed expectantly were matched with the treatment group in terms of transvaginal cervical length at diagnosis (±3 mm), gestational age at presentation of diagnosis (±3 weeks), and maternal age (±5 years). An additional subanalysis was performed in which the patients were divided into 2 subgroups based on transvaginal cervical length of either <15 mm or between 15 and 24 mm. The primary outcome was gestational age at delivery. The secondary outcomes were pregnancy latency, the rate of spontaneous preterm birth at <28, <32, <34, <36 weeks' gestation, and neonatal outcomes.

RESULTS

A total of 90 twin pregnancies with a transvaginal cervical length <25 mm were managed with either a cerclage (ultrasound-indicated cerclage group, n=45) or expectantly (control group, n=45). Demographic characteristics were not significantly different between the groups. When compared with the control group, the gestational age at delivery was significantly higher (33.11±3.16 vs 30.22±4.12 weeks; P=.001) and the pregnancy latency was significantly longer (72.40±22.51 vs 45.56±28.82 days; P<.001) in the ultrasound-indicated cerclage group. The rates of spontaneous preterm birth at <28, <32, <34, and <36 weeks' gestation were significantly lower in the ultrasound-indicated cerclage group than in the control group. In terms of neonatal outcomes, there were significant reductions in the overall perinatal mortality (4.4% vs 20.0%; P<.001), neonatal intensive care unit admissions (69.0% vs 92.6%; P<.001), and composite adverse neonatal outcomes (43.7% vs 64.7%; P=.010) for the ultrasound-indicated cerclage group when compared with the control group. In the subgroup of women with a transvaginal cervical length of between 15 and 24 mm (with 21 in the ultrasound-indicated cerclage group vs 21 controls), the data were adjusted for maternal age, pregestational body mass index, in vitro fertilization, operative hysteroscopy, previous cervical surgery, previous spontaneous preterm birth, white blood cell counts, C-reactive protein level, neutrophil to lymphocyte ratio, and the shortest transvaginal cervical length measured at diagnosis. In ultrasound-indicated cerclage group, gestational age at delivery was significantly higher (32.95±3.81 vs 30.24±4.01 weeks; beta, 3.34; 95% confidence interval, 0.14-6.55; P=.042), pregnancy latency was significantly prolonged (77.19±24.81 vs 48.52±29.67 days; beta, 33.81; 95% confidence interval, 12.29-55.34; P=.003), and the rates of spontaneous preterm birth <36 weeks' gestation (57.1% vs 95.2%; adjusted odds ratio, 0.03; 95% confidence interval, 0.01-0.69; P=.029) was significantly decreased, and for neonatal outcomes, there were significant reductions in neonatal intensive care unit admissions (53.7% vs 96.7%; adjusted odds ratio, 0.04; 95% confidence interval, 0.01-0.32; P=.003) and the composite adverse neonatal outcomes (39.0% vs 73.3%; adjusted odds ratio, 0.24; 95% confidence interval, 0.08-0.68; P=.008) in the ultrasound-indicated cerclage group when compared with the control group. In the subgroup of women with a transvaginal cervical length <15 mm, gestational age at delivery was higher (33.25±2.52 vs 30.00±4.33 weeks; beta, 3.96; 95% confidence interval, 1.51-6.42; P=.002), pregnancy latency was significantly prolonged (68.21±19.85 vs 42.96±28.43 days; beta, 30.11; 95% confidence interval, 12.42-47.81; P=.001), rates of spontaneous preterm birth at <32 weeks (16.7% vs 54.2%; adjusted odds ratio, 0.10; 95% confidence interval, 0.01-0.61; P=.020) and <34 weeks (54.2% vs 83.3%, adjusted odds ratio, 0.08; 95% confidence interval, 0.01-0.66; P=.019) of gestation was significantly decreased, and neonatal birthweight was significantly increased (2023.96±510.35 vs 1421.77±611.40 g; beta, 702.40; 95% confidence interval, 297.02-1107.78; P=.001) in the ultrasound-indicated cerclage group when compared with the control group.

CONCLUSION

Cerclage among women with twin pregnancies with a transvaginal cervical length <25 mm may reduce the rate of spontaneous preterm birth and improve perinatal and neonatal outcomes when compared with expectant management. It is worth noting that even with a short transvaginal cervical length of 15 to 24 mm, cerclage will significantly decrease the risk of delivery at <36 weeks' gestation and prolong pregnancy latency. Among women with a short transvaginal cervical length <15 mm, cerclage will significantly decrease the risk of delivery at <32 and <34 weeks' gestation and prolong pregnancy latency.

Comparison of emergency cervical cerclage and expectant treatment in cervical insufficiency in singleton pregnancy: A meta-analysis

OBJECTIVE

To compare the therapeutic effects of emergency cervical cerclage and expectant treatment in preterm birth due to cervical insufficiency in singleton pregnancy.

METHODS

A combination of subject words and free words was used to search major domestic and foreign databases. According to inclusion and exclusion criteria, 23 studies were included that met the criteria and quality evaluation and data extraction was carried out. The data were analyzed using STATA 15 and the reporting was done in reference to the list of Preferred Reporting Items for Systematic and Meta-Analyses.

RESULTS

Emergency cervical cerclage was superior to expectant treatment for the primary outcome of pregnancy prolongation (WMD = 5.752, 95% CI 5.194-6.311, 22 studies, N = 1435, I2 = 97.1%, P = 0.000). Cervical cerclage was also superior to expectant treatment for the secondary outcomes of neonatal birth weight (WMD = 1051.542, 95% CI 594.107-1508.977, 9 studies, N = 609, I2 = 96.4%, P = 0.000), neonatal Apgar 1' (WMD = 2.8720, 95% CI: 2.105-3.639, 11 studies, N = 716, I2 = 99.0%, P = 0.000), number of live births (OR = 6.018, 95% CI 2.882-12.568, 10 studies, N = 724, I2 = 55.3%, P = 0.000), deliveries after 32 weeks (OR = 8.030, 95% CI 1.38-46.892, 8 studies, N = 381, I2 = 85.9%, P = 0.021). deliveries after 34 weeks (OR = 15.91, 95% CI 5.92-42.77, 9 studies, N = 560, I2 = 59.6%, P = 0.000), number of vaginal deliveries (OR = 3.24, 95% CI 1.32-7.90, 8 studies, N = 502, I2 = 69.4%, P = 0.018), and number of neonatal survivals (OR = 9.300, 95% CI 3.472-24.910, 10 studies, N = 654, I2 = 80.5%, P = 0.000). No difference between emergency cervical cerclage and expectant treatment was found in patients with chorioamnionitis (OR = 1.85, 95% CI 0.602-4.583, 4 studies, N = 296, I2 = 16.3%, P = 0.273).

CONCLUSION

Before the 28th week of pregnancy, emergency cervical cerclage can significantly prolong the gestational week and improve the neonatal survival rate, compared to expectant treatment, in women with singleton pregnancies who have a dilated uterine orifice caused by cervical insufficiency.

McDonald versus Shirodkar cerclage technique in the prevention of preterm birth: A systematic review and meta-analysis

BACKGROUND

Cervical cerclage has been used for decades to reduce preterm birth. The Shirodkar and McDonald cerclage are the most commonly used techniques with no current consensus on the preferred technique.

OBJECTIVE

To compare the efficacy of the Shirodkar and McDonald cerclage techniques in preventing preterm birth.

SEARCH STRATEGY

Studies were sourced from six electronic databases and reference lists.

SELECTION CRITERIA

Studies including women with a singleton pregnancy, requiring a cervical cerclage, using either the Shirodkar or McDonald technique that ran comparative analyses between the two techniques.

DATA COLLECTION AND ANALYSIS

The primary outcome was preterm birth before 37 weeks, with analyses at 28, 32, 34 and 35 weeks. Secondary data were also collected on neonatal, maternal and obstetric outcomes.

MAIN RESULTS

Seventeen papers were included: 16 were retrospective cohort studies and one was a randomised controlled trial. The Shirodkar technique was significantly less likely to result in preterm birth before 37 weeks than the McDonald technique (relative risk [RR] 0.91, 95% CI 0.85-0.98). This finding was supported by a statistically significant reduction in rates of preterm birth before 35, 34 and 32 weeks, PPROM, difference in cervical length, cerclage to delivery interval, and an increase in birthweight in the Shirodkar group. No difference was seen in preterm birth rates <28 weeks, neonatal mortality, chorioamnionitis, cervical laceration or caesarean section rates. The RR for preterm birth prior to 37 weeks was no longer significant when sensitivity analyses were performed removing studies with a serious risk of bias. However, similar analyses removing studies that utilised adjunctive progesterone strengthened the primary outcome (RR 0.83, 95% CI 0.74-0.93).

CONCLUSION

Shirodkar cerclage reduces the rate of preterm birth prior to 35, 34 and 32 weeks' gestation when compared with McDonald cerclage; however, the overall quality of the studies in this review is low. Further, large, well-designed randomised controlled trials are required to address this important question to optimise care for women who may benefit from cervical cerclage.

A Retrospective Cohort Study on Maternal and Neonatal Clinical Characteristics and Outcomes of COVID-19: Does the Gestational Age Affect the Outcome?

Background To evaluate the maternal and neonatal clinical characteristics and outcomes of COVID-19 during pregnancy and to see whether infection with COVID-19 before or after the 20th gestational week affects these outcomes. Methods We conducted a retrospective study with data from pregnant women who were followed up and delivered at Acibadem Maslak Hospital between April 2020 and December 2021. Their demographics and clinical data were reviewed and compared. Results Among 1223 pregnant women, 42 (3.4%) were diagnosed with COVID-19 (SARS-CoV-2-positive). Approximately 52.4% of the 42 pregnant women with COVID-19 were diagnosed during or before the 20th gestational week, while 47.6% were positive after the 20th gestational week. The preterm birth rate was 11.9% and 5.9% in infected and uninfected pregnant women, respectively (p>0.05). In the infected pregnant women, the rate of preterm rupture of membranes (PROM) was 2.4%, small for gestational age (SGA) was 7.1%, cesarean delivery was 76.2%, and neonatal intensive care unit (NICU) admission was 9.5%. These rates among uninfected women were 0.9%, 9.1%, 61.7%, and 4.1%, respectively (p>0.05). Maternal ICU admission and intrapartum complications were higher in infected pregnant women (p>0.05). Postpartum hemorrhage (PPH), intrauterine growth retardation (IUGR), neonatal infection, and fetal demise were absent in SARS-CoV-2-positive pregnant women. Having a high school or lower education level significantly increased the risk of SARS-CoV-2 infection during pregnancy 10 times. Also, a one-week increase in gestational age significantly reduced the risk of SARS-CoV-2 infection during pregnancy. When SARS-CoV-2-positive pregnant women were compared according to whether or not they were positive before or after the 20th gestational week, there was no statistically significant difference between the two groups in terms of maternal outcomes, neonatal outcomes, and demographic characteristics. Conclusions COVID-19 during pregnancy did not adversely affect maternal and neonatal outcomes. Also, whether pregnant women were infected before or after the 20th gestational week did not have a negative impact on maternal and neonatal outcomes. However, infected pregnant women should be followed closely, and they should be informed in detail about the possible adverse outcomes and the importance of precautions for COVID-19.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Amnioreduction with rescue cerclage at advanced cervical dilation or gestational age

OBJECTIVE

To determine the feasibility of rescue cerclage and amnioreduction at advanced cervical dilation or gestational age.

METHODS

We present a retrospective case series of women who underwent rescue cerclage at either an advanced gestational age (24 + 0 to 24 + 6 weeks) or cervical dilation (≥4 cm), with a subset undergoing amnioreduction prior to cerclage placement.

RESULTS

Nine women were included and amnioreduction was performed in 7 (78%). A bi-modal distribution of obstetric outcomes was observed, with 5 (56%) women delivering ≥34 weeks gestation, 3 (33%) of which delivered at term. Two (22%) women experienced intra-operative rupture of membranes and subsequent perinatal deaths. Two (22%) women delivered extremely premature, with one resulting in infant death.

DISCUSSION

Our data show that rescue cerclage with amnioreduction may be successful at advanced gestational ages or cervical dilations, suggesting that these women should be included in prospective studies to better establish the efficacy and safety of this procedure.

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.

Identification of risk factors for incident cervical insufficiency in nulliparous and parous women: a population-based case-control study

BACKGROUND

Cervical insufficiency is one of the underlying causes of late miscarriage and preterm birth. Although many risk factors have been identified, the relative magnitude of their association with risk in nulliparous versus parous women has not been well demonstrated, especially for incident cervical insufficiency (ICI). The aim of this study was to investigate and compare the magnitude of the association of ICI with predictive factors in nulliparous and parous women, and to further investigate various aspects of obstetric history for parous women.

METHODS

Pregnant women with a first diagnosis of cervical insufficiency were compared to a random sample of control pregnancies from women with no diagnosis by using Swedish national health registers. Demographic, reproductive, and pregnancy-specific factors were compared in case and control pregnancies, and relative risks presented as odds ratios (OR), stratified by nulliparous/parous. Independent associations with ICI were estimated from multivariable logistic regression. Associations with obstetric history were further estimated for multiparous women.

RESULTS

A total of 759 nulliparous ICI cases and 1498 parous cases were identified during the study period. Multifetal gestation had a strong positive association with ICI in both groups, but of much larger magnitude for nulliparous women. The number of previous miscarriages was also a much stronger predictor of risk in nulliparous women, especially for multifetal pregnancies. History of preterm delivery (<37 weeks' gestation) was an independent predictor for parous women, and for those whose most recent delivery was preterm, the association with ICI increased with each additional week of prematurity. A previous delivery with prolonged second stage of labor or delivery of a very large infant were both inversely associated with risk of ICI in the current pregnancy.

CONCLUSIONS

The differences in importance of predictive risk factors for incident cervical insufficiency in nulliparous and parous women can help resolve some of the inconsistencies in the literature to date regarding factors that are useful for risk prediction. Stratifying on parity can inform more targeted surveillance of at-risk pregnancies, enable the two groups of women to be better informed of their risks, and eventually inform screening and intervention efforts.

A nomogram to predict extremely preterm birth in women with singleton pregnancies undergoing cervical cerclage

Objective

To develop a nomogram to predict preterm birth before 28 weeks in pregnant women undergoing cervical cerclage.

Study design

We retrospectively studied the medical records on pregnant women who underwent cervical cerclage in January 2016 to September 2020. We developed the model from a development cohort in Women's Hospital, Zhejiang university, School of medicine, which randomly divided by 7:3 into training cohort for nomogram development, and internal validation cohort to confirm the model's performance. We then tested the nomogram in an external validation cohort over a similar period. The Harrell's C-index, calibration curve, decision curve analyses (DCA) were performed to assess the model.

Results

528 patients formed the development cohort, and 97 patients formed the external validation cohort. The model initially incorporated 10 baseline variables, while 5 variables were estimated in the nomogram at last: history of prior second-trimester loss, use of in-vitro fertilization (IVF), cervical dilation at cerclage, C-reactive protein (CRP) and platelet-lymphocyte ratio (PLR). The nomogram achieved good concordance indexes of 0.82(95%CI 0.77–0.88), 0.80(95%CI 0.72–0.88) and 0.79 (95%CI 0.68–0.90) in the training, internal and external validation cohort, respectively. And the nomogram had well-fitted calibration curves. Decision curve analysis demonstrated that the nomogram was clinically useful.

Conclusions

The well-performed nomogram graphically represents the risk factors and a pre-operative predicted model in predicting the risk of preterm birth at <28 weeks in singleton pregnant women undergoing cervical cerclage. The model can provide a useful guide for clinicians and patients in making appropriate clinical decisions.

Guideline No. 428: Management of Dichorionic Twin Pregnancies

OBJECTIVE

To review evidence-based recommendations for the management of dichorionic twin pregnancies.

TARGET POPULATION

Pregnant women with a dichorionic twin pregnancy.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in this guideline may improve the management of twin pregnancies and reduce neonatal and maternal morbidity and mortality.

EVIDENCE

Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (e.g., twin, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for women with twin pregnancies.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Analysis of the Timing of Cervical Cerclage Treatment in Pregnant Women with Cervical Insufficiency and the Effect on Pregnancy Outcome

Purpose

To analyze the effect of the choice of timing of cervical cerclage treatment on pregnancy outcome in pregnant women with cervical insufficiency (CI).

Methods

The case data of 160 pregnant women admitted to our hospital for cervical cerclage due to CI from January 2020 to September 2021 were sampled. They were divided into the early group (14∼18 weeks of pregnancy, n = 86), the middle group (19∼27 weeks of pregnancy, n = 74) according to the different gestational periods of surgical treatment, and into the elective group (elective operation, n = 71) and the emergency group (emergency operation, n = 89) according to the different timings of surgical treatment. To compare the pregnancy outcomes of the four groups and the effects of different treatment timings on pregnant women and newborns.

Results

After the operation, the intrauterine infection rate in the early group was lower (8.14% (7/86)) than that (71.62% (53/74)) in the middle group, and the intrauterine infection rate (18.31% (13/71)) in the elective group was lower (61.80% (55/89)) than that in the emergency group (P < 0.05). After the operation, the late abortion rate in the early group was 8.14% (7/86) lower than 63.51% (47/74) in the middle group, and the late abortion rate in the elective group was 15.49% (11/71) lower than 61.80% (55/89) in the emergency group (P < 0.05). After the operation, the full-term birth rate (82.56% (71/86)) in the early group was higher (21.62% (16/74)) than that in the middle group, and the full-term birth rate (73.24% (52/71)) of the elective group was higher (24.72% (22/89)) than that in the emergency group (P < 0.05). After the operation, there was no significant difference in the preterm birth rate between the early group and the middle group (8.14% vs 14.86%), and between the elective group and the emergency group (11.27% vs 12.36%) (P > 0.05). There was no significant difference in neonatal Apgar scores between the early group and the middle group (7.30 ± 0.98 vs 7.14 ± 0.91) scores, and between the selective group and the emergency group (7.15 ± 0.82 vs 7.07 ± 1.07) scores (P > 0.05). There was no significant difference in gestational week extension time between the early group and the middle group (6.52 ± 1.77 vs 6.99 ± 1.69) days and between the elective group and the emergency group (6.44 ± 1.37 vs 6.82 ± 1.70) days (P > 0.05). The length of hospital stay was (7.28 ± 1.39 vs 10.89 ± 2.65) days in the early group and the middle group, with the early group being shorter than the middle group (P < 0.05), and the length of hospital stay was (8.72 ± 1.23 vs 9.30 ± 1.39) days in the elective group and the emergency group, with the elective group being shorter than the emergency group (P < 0.05).

Conclusions

The therapeutic effect and pregnancy outcome of cervical cerclage are affected by the timing of treatment. Among them, the effect of elective operation at 14∼18 weeks of pregnancy is more ideal, which is worthy of clinical promotion.

Clinical analysis of 2860 cases of diabetes in pregnancy: a single-center retrospective study

Background

To investigate the epidemiological, clinical characteristics and outcomes of diabetes in pregnancy (DIP).

Methods

This single-center, retrospective study included 16,974 pregnant women hospitalized during 2018–2019. Among them, 2860 DIP patients were grouped according to diabetes type, glycemic status, and insulin use. Multivariate logistic regression analysis was conducted.

Results

The incidence of DIP [17.10%; pregestational diabetes mellitus (PGDM), 2.00% (type I, 0.08%; type 2, 1.92%); gestational diabetes mellitus (GDM), 14.85% (GDM A1, 13.58%; GDM A2, 1.27%)] increased annually. Premature birth, congenital anomalies, large for gestational age (LGA), neonatal asphyxia, neonatal intensive care unit transfer, hypertension, and puerperal infection were more common in DIP than in healthy pregnancies. The most common comorbidities/complications were hypertension, thyroid dysfunction, cervical incompetence, intrahepatic cholestasis, premature membrane rupture, oligo/polyhydramnios, and fetal distress. GDM incidence at ages ≥35 and ≥ 45 years was 1.91 and 3.26 times that at age < 35 years, respectively. If only women with high-risk factors were screened, 34.8% GDM cases would be missed. The proportion of insulin use was 14.06% (PGDM, 55%; GDM, 8.53%). Mean gestational age at peak insulin dose in DIP was 32.87 ± 5.46 weeks. Peak insulin doses in PGDM and GDM were 3.67 and 2 times the initial doses, respectively. The risks of LGA, premature birth, cesarean section, and neonatal hypoglycemia in PGDM were 1.845, 1.533, 1.797, and 1.368 times of those in GDM, respectively. The risks of premature birth and neonatal hypoglycemia in women with poor glycemic control were 1.504 and 1.558 times of those in women with good control, respectively.

Conclusions

The incidence of adverse outcomes in DIP is high.

Progesterone, cervical cerclage or cervical pessary to prevent preterm birth: a decision-making analysis of international guidelines

Objective

The aim of this study was to investigate guidelines on preterm birth, analyze decision-criteria, and to identify consensus and discrepancies among these guidelines.

Design

Objective consensus analysis of guidelines.

Sample

Ten international guidelines on preterm birth.

Methods

Relevant decision criteria were singleton vs. twin pregnancy, history, cervical length, and cervical surgery / trauma or Mullerian anomaly. Eight treatment recommendations were extracted. For each decision-making criteria the most commonly recommended treatment was identified, and the level of consensus was evaluated.

Main outcome measures

Consensus and Discrepancies among recommendations.

Results

In a case of singleton pregnancies with no history of preterm birth and shortened cervix, most guidelines recommend progesterone. In singleton pregnancies with a positive history and shortened cervix, all guidelines recommend a cerclage as an option, alternative or conjunct to progesterone. The majority of the guidelines advise against treatment in twin pregnancies.

Conclusions

A shortened cervix and a history of preterm birth are relevant in singleton pregnancies. In twins, most guidelines recommend no active treatment.

Tweetable abstract

Among international guidelines a shortened cervix and a history of preterm birth are relevant in singleton pregnancies. With no history of preterm birth and with a shortened cervix most guidelines recommend progesterone treatment.

Guidelines on prevention of preterm birth

This guideline has been prepared by the National Maternal Fetal Medicine guidelines committee and approved by the Society of Obstetricians and Gynecologists Pakistan. These recommendations will enable the practicing clinicians to optimally manage pregnancies at risk of preterm birth.

The retrospective study for effectiveness of cervical cerclage in preventing recurrent preterm birth

OBJECTIVE

This study aimed to clarify the effectiveness of cervical cerclage in preventing recurrent preterm births.

MATERIALS AND METHODS

A retrospective study was conducted using the perinatal registration database of the Japan Society of Obstetrics and Gynecology for the Perinatal Center from 2014 to 2016. The efficacies of history-indicated, ultrasound-indicated, and physical examination-indicated cerclage as preventive treatments for women with a history of preterm birth were evaluated by comparing cerclage and non-cerclage cases. Fisher's exact test was performed to evaluate any significant differences in patient backgrounds. Prior to the evaluation, propensity score matching was performed for history-indicated and ultrasound-indicated cerclage patients.

RESULTS

For this study, 6060 multiparous women with a history of preterm birth were reviewed. After excluding 17 patients with unknown indications for cervical cerclage, 6043 patients were included in the study. History-indicated and ultrasound-indicated cerclage did not reduce the risk of preterm birth in subsequent pregnancies for any of the pregnancy periods (p = 0.413, p = 1.000). In contrast, physical examination-indicated cerclage significantly reduced the risk of subsequent preterm births for all pregnancy periods (p < 0.001).

CONCLUSION

Subsequent preterm births were effectively prevented only in physical examination-indicated cerclage cases. For history- or ultrasound-indicated cerclage, statistically significant differences in subsequent preterm births were not evident.

Effects of Anticoagulants and Immune Agents on Pregnancy Outcomes and Offspring Safety in Frozen-Thawed Embryo Transfer Cycles-A Retrospective Cohort Study

The application of anticoagulants and immune agents in assisted reproduction technology has been in a chaotic state, and no clear conclusion has been reached regarding the effectiveness and safety of this treatment. We aimed to explore the potential association between adjuvant medication and pregnancy outcomes and offspring safety in a retrospective cohort study including 8,873 frozen-thawed embryo transfer cycles. The included cycles were divided into three groups according to the drugs used, namely, the routine treatment group (without anticoagulant agents and immune agents), the anticoagulant agent group, and the immunotherapy group. Among normal ovulatory patients, those who used immune agents had a 1.4-fold increased risk of miscarriage (≤13 weeks), but a 0.8-fold decreased chance of birth (≥28 weeks) compared with the routine treatment group. Among patients with more than 1 embryo transferred, those who used anticoagulant agents showed a 1.2-fold higher risk of multiple birth than those undergoing routine treatment. Among patients without pregnancy complications, anticoagulant treatment was associated with a 2.1-fold increased risk of congenital anomalies. Among young patients (<26 years) with a singleton pregnancy, the neonatal birth weight of the immunotherapy group and the anticoagulant treatment group was 305.4 g and 175.9 g heavier than the routine treatment group, respectively. In conclusion, adjuvant anticoagulants or immune agent treatment in assisted reproductive technology should be used under strict supervision, and the principle of individualized treatment should be followed.

Endothelial dysfunction in preterm infants: The hidden legacy of uteroplacental pathologies

Millions of infants are born prematurely every year worldwide. Prematurity, particularly at lower gestational ages, is associated with high mortality and morbidity and is a significant global health burden. Pregnancy complications and preterm birth syndrome strongly impact neonatal clinical phenotypes and outcomes. The vascular endothelium is a pivotal regulator of fetal growth and development. In recent years, the key role of uteroplacental pathologies impairing endothelial homeostasis is emerging. Conditions leading to very and extremely preterm birth can be classified into two main pathophysiological patterns or endotypes: infection/inflammation and dysfunctional placentation. The first is frequently related to chorioamnionitis, whereas the second is commonly associated with hypertensive disorders of pregnancy and fetal growth restriction. The nature, timing, and extent of prenatal noxa may alter fetal and neonatal endothelial phenotype and functions. Changes in the luminal surface, oxidative stress, growth factors imbalance, and dysregulation of permeability and vascular tone are the leading causes of endothelial dysfunction in preterm infants. However, the available evidence regarding endothelial physiology and damage is limited in neonates compared to adults. Herein, we discuss the current knowledge on endothelial dysfunction in the infectious/inflammatory and dysfunctional placentation endotypes of prematurity, summarizing their molecular features, available biomarkers, and clinical impact. Furthermore, knowledge gaps, shadows, and future research perspectives are highlighted.

Peripartum cardiomyopathy and acute heart failure associated with prolonged tocolytic therapy in pregnancy: A case report

RATIONALE

Peripartum cardiomyopathy (PPCM) is a rare and sometimes fatal systolic heart failure that affects women during late pregnancy or the early postpartum period. Heart failure symptoms can mimic the physiological changes of normal pregnancy, and the diagnosis is based on echocardiography.

PATIENT CONCERNS

A 38-year-old multiparous woman with a history of cervical incompetence underwent cervical cerclage and received tocolysis for 100 days.

DIAGNOSES

She delivered vaginally at 37 weeks of gestation but developed postpartum decompensated acute heart failure with low left ventricular ejection fraction (LVEF: 34%) and was diagnosed with PPCM.

INTERVENTIONS

She received standard therapy for acute heart failure.

OUTCOMES

The patient's pulmonary edema cleared, and she was fully ambulatory 6 days after admission. A follow-up echocardiogram 3 months later demonstrated recovery of LVEF to 66%.

LESSONS

Prolonged tocolysis may contribute to cardiomyopathy and should be used with caution. PPCM management requires standard treatments for acute heart failure with modifications for fetal safety.