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

Comparison of Pregnancy Outcomes of History-Indicated and Ultrasound-Indicated Cervical Cerclage: A Retrospective Cohort Study

Background

Cervical cerclage is the procedure of choice for preventing preterm delivery due to cervical insufficiency. The indication for its application may be based on the woman's reproductive history, findings at ultrasound, or clinical findings on vaginal examination. Pregnancy outcomes from these indications are variable according to the available literature.

Objective

To compare the effectiveness and reproductive outcomes (miscarriage, preterm birth rates, and birth weights) of McDonald's cervical cerclage after history-indicated and ultrasound-indicated cervical cerclage in pregnant women.

Methods

The retrospective cohort study was conducted at Life International Hospital Awka, Nigeria and Life Specialist Hospital Nnewi, Nigeria. Pregnant women, who had a McDonald's cervical cerclage performed due to either history or ultrasound indication between January 1, 2011, and December 31, 2020, were included in the study. Women with multiple pregnancies and those with physical examination-indicated or emergency cerclages were excluded. The main outcome measures included the prevalence of cervical cerclage, miscarriage, and preterm delivery rates. Outcomes were compared between groups with the chi-square test, Fisher's exact test, or Student's t test. p value of < 0.5 was set as significant value.

Results

Overall, during the study period, 5392 deliveries occurred in the study sites, of which 103 women had a history-indicated or ultrasound-indicated cervical cerclage. This resulted in a 1.91% prevalence rate for history-indicated and ultrasound-indicated cervical cerclage. Of these, 68 (66%) had history indicated, while 35 (34%) had ultrasound-indicated cerclage. There was no difference in the sociodemographic characteristics of both groups. Both groups had similar miscarriage rates: 1.18 in 1000 and 1.04 in 1000 deliveries, respectively (RR 1.160, 95% CI: 0.3824 to 3.5186, p = 0.793). There was more preterm delivery in history-indicated cerclage than ultrasound-indicated cervical cerclage (26.50% vs. 17.10%; p = 0.292), though the difference was not statistically significant. The ultrasound group had a higher average birthweight than the history group (2.67 ± 0.99 vs. 2.53 ± 0.74). However, this difference was not statistically significant.

Conclusion

The effectiveness and reproductive outcomes (miscarriage, preterm birth rates, and birth weights) of pregnant women with cervical cerclage due to history-indicated and ultrasound-indicated cervical cerclage appear similar. When needed, cervical cerclage should be freely applied for cervical insufficiency, irrespective of the type of indication.

Surgical excision of benign spindle cell neoplasm of the cervix predating miscarriage due to cervical insufficiency: A case report

This case report is on cervical spindle cell neoplasm and complications of its excision. A 34-year-old multiparous woman presented with a one-year history of mild to moderate non-radiating lower abdominal pain and a sensation of a mass in the vagina when urinating. These symptoms were associated with a recurrent foul-smelling yellow vaginal discharge which was unresponsive to antibiotic therapy prescribed at a primary healthcare clinic. Vaginal examination at a gynaecological clinic revealed a firm circular cervical mass. Excision biopsy of the mass (attached between the 1 and 3 o'clock positions on the cervix) showed a benign spindle cell neoplasm. The patient became pregnant six months after the surgical excision and had a miscarriage at 18 weeks of gestation due to cervical insufficiency. The report highlights the importance of antenatal surveillance for women following surgical excision of a cervical lesion such as spindle cell neoplasm as they may be predisposed to cervical insufficiency.

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Cervical insufficiency results from a defect in the mechanical properties of the cervix.

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Cervical surgery predisposes to cervical insufficiency.

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Spindle cell tumour of the cervix is rare and its excision weakens the cervix.

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Surveillance of the cervix is required in pregnancy after cervical surgery.

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Cerclage is recommended after cervical surgery for women with a history of preterm delivery.

Tocolytic Treatment for the Prevention of Preterm Birth from a Taiwanese Perspective: A Survey of Taiwanese Obstetric Specialists

Preterm birth represents a great burden to the healthcare system, resulting in the consideration for the use of tocolytic therapy to provide a "better time" for delivery in order to buy time to accelerate fetal lung maturity, thereby minimizing prematurity-related morbidity and mortality. However, the benefits and potential side effects and risks of tocolytic treatment for preterm birth should be carefully balanced. Although many countries and societies provide guidelines or consensuses for the management for preterm birth, there is no standardized national guideline or consensus in Taiwan. As such, great heterogeneity is suspected in preterm labor management, contributing to the uncertainty of attitudes and practice patterns of obstetric specialists in Taiwan. This study attempts to understand the attitudes and practice patterns regarding tocolytic therapy in Taiwan. A paper-based survey was conducted at the 2020 Taiwan Society of Perinatology Conference on 8 December 2020, exploring how obstetric specialists would use tocolytics under nine different clinical scenarios, such as a short cervix, preterm labor, maintenance tocolysis, preterm premature rupture of membranes, etc. Three hundred ten specialists attended the conference, and 77 responded to the survey with a response rate of 24.8%. According to the survey, many of these specialists would prescribe tocolytics for less evidence-based indications, including 22% for abdominal tightness, 46% for a short cervix, 60% for maintenance tocolysis, and 89% for repeat tocolysis, with the preferred first line medication being ritodrine and nifedipine. We concluded that tocolysis is widely accepted and practiced in Taiwan. More research is needed to include Taiwan-specific economic and cultural factors as well as associated adverse effects and patients' outcomes.