Does cerclage location influence perinatal outcome?

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.

Shirodkar cerclage: Obstetrical and neonatal outcomes in a single-center cohort of 55 cases

BACKGROUND

Cervical insufficiency is thought to be responsible for 10% of preterm deliveries. Shirodkar cerclage is among the available techniques ranging from McDonald's to definitive procedures, however the indications for the prevention of preterm births and mid-trimester miscarriages are still poorly delineated.

OBJECTIVE

To describe the characteristics, obstetrical and neonatal outcomes of pregnancies with Shirodkar cerclage procedures.

METHOD

We performed a descriptive retrospective single-center study, including all patients who had a Shirodkar cerclage between January 1, 2008 and December 31, 2020. The main outcomes measured were delivery at or beyond 24 and 32 weeks of gestations (WG).

RESULTS

55 Shirodkar cerclages were performed over the period studied. 7.3% of patients had a uterine malformation, 9% had a history of cervical conization. 74.5% had history of one or more mid-trimester miscarriages. 63.6% had a history of a failed emergency or prophylactic cerclage. The median gestational age (GA) at cerclage placement was 14 WG. There were 4 deliveries before 24 WG, 8 before 32 WG and 16 before 37 WG. Overall neonatal survival was 48/53 (90.6%). The median GA at delivery was 38 weeks (IQR 35-39), with 70.3% of vaginal deliveries.

CONCLUSION

Shirodkar cerclage was successful in more than 90% of patients, despite their obstetric history. Shirodkar cerclage may be indicated in the event of prior cerclage failure using the McDonald technique or in order to allow for correct stitch placement in very short cervixes. Its advantage over definitive cerclage is to allow for vaginal delivery.

The association between sonographic cervical length components and preterm birth in women with ultrasound- or exam-indicated cerclage

OBJECTIVE

To evaluate which parameters of a sonographic cervical length measurement are associated with preterm birth in women with ultrasound- or exam-indicated cerclage.

METHODS

This was a retrospective cohort study of women with singleton pregnancies who underwent ultrasound- or exam-indicated Shirodkar cerclage by a single maternal-fetal medicine practice between 2011 and 2019. All patients underwent sonographic cervical length measurement 2-3 weeks after cerclage placement, and then every 2-4 weeks up to 32 weeks. The images from the first and second post-cerclage cervical lengths were reviewed. Total cervical length, upper cervical length (from the internal cervical os to the cerclage), and lower cervical length (from the cerclage to the external os) were measured. The primary outcome for this study was gestational age at delivery.

RESULTS

A total of 114 women with cerclage were included (85 (74.6%) ultrasound-indicated and 29 (25.4%) exam-indicated). The first and second total cervical lengths correlated with gestational age at delivery (r = 0.26, p=.005; r = 0.33, p<.001, respectively), and the change from first to second was inversely correlated with gestational age at delivery (r = -0.20, p=.032). The first and second upper cervical lengths also correlated with gestational age at delivery (r = 0.22, p = .019; r = 0.33, p<.001, respectively), and the change from first to second upper cervical length was inversely correlated with gestational age at delivery (r= -0.20, r = 0.029). Neither the first nor the second lower cervical lengths were significantly associated with gestational age at delivery. On regression analysis, total cervical length and upper cervical length were not independently associated with gestational age at delivery (p = .108 and p=.806, respectively, for the first scan; p = .153 and p=.166, respectively, for the second scan).

CONCLUSIONS

Postcerclage total cervical length and upper cervical length are both associated with gestational age at delivery and risk of preterm birth, but not independently. After ultrasound- or exam-indicated cerclage, sonographic monitoring of either the total cervical length or the upper cervical length might be predictive of gestational age at delivery and the risk of preterm birth.

The Short Cervix: A Critical Analysis of Diagnosis and Treatment

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

The role of three-dimensional ultrasound in pregnancies submitted to cerclage

OBJECTIVE

Cervical cerclage is the standard treatment for cervical incompetence (CI); however, there is still a high risk of preterm birth for women who undergo this treatment. The aim of this study was to longitudinally evaluate findings on two-dimensional transvaginal ultrasonography (2DTVUS) and three-dimensional transvaginal ultrasonography (3DTVUS) that could be related to gestational age at birth.

METHODS

A total of 68 pregnant women who were treated with cerclage were evaluated by 2DTVUS and 3DTVUS in the second and third trimesters of pregnancy. Log-rank tests and Cox regression analyses were used to identify significant findings related to gestational age at delivery.

RESULTS

A cervical length lower than 281 mm (p= 0.0083), a proximal cervical length lower than 10 mm (p= 0.0151), a cervical volume lower than 18.17 cm3 (p= 0.0152), a vascularization index (VI) under 2.153 (p= 0.0044), and a vascularization-flow index (VFI) under 0.961 (p= 0.0059) in the second trimester were all related to earlier delivery. In the third trimester, a cervical length lower than 20.4 mm (p= 0.0009), a VI over 0.54 (p= 0.0327) and a VFI over 2.275 (p= 0.0479) were all related to earlier delivery. Cervical funnelling in the second and third trimesters and proximal cervical length in the third trimester were not related to gestational age at birth. The COX regression analyses showed that cervical volume in the second trimester; FI and VFI in the third trimester were significantly associated with gestational age at birth.

CONCLUSION

In women treated with history-indicated cerclage or ultrasound-indicated cerclage, 2nd trimester cervical volume and 3rd trimester FI and VFI are independent significant sonographic findings associated with time to delivery.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cerclage position, cervical length and preterm delivery in women undergoing ultrasound indicated cervical cerclage: A retrospective cohort study

Objective

The objectives were to assess whether anatomical location of ultrasound (USS) indicated cervical cerclage and/or the degree of cervical shortening (cervical length; CL) prior to and following cerclage affects the risk of preterm birth (PTB).

Method

A retrospective cohort study of 179 women receiving cerclage for short cervix (≤25mm) was performed. Demographic data, CL before and after cerclage insertion, height of cerclage (distance from external os) and gestation at delivery were collected. Relative risk (RR) and odds ratio (OR) of preterm delivery were calculated according to the anatomical location of the cerclage within the cervix and the CL before and after cerclage as categorical and continuous variables. Partition tree analysis was used to identify the threshold cerclage height that best predicts PTB.

Results

25% (n = 45) delivered <34 weeks and 36% (n = 65) delivered <37 weeks. Risk of PTB was greater with cerclage in the distal 10mm (RR2.37, 95% CI 1.45–3.87) or the distal half of a closed cervix (RR2.16, 95% CI 1.45–3.87). Increasing absolute cerclage height was associated with a reduction in PTB (OR 0.87, 95% CI 0.82–0.94). A cerclage height <14.5 mm best predicts PTB (70.8%). Increasing CL following cerclage was associated with a reduction in PTB (OR0.87, 95% CI 0.82–0.94). Conversely, the risk of PTB was increased where CL remained static or shortened further following cerclage (RR2.34, 95% CI 1.04–5.25).

Conclusion

The higher a cerclage was placed within a shortened cervix, the lower the subsequent odds of PTB. Women whose cerclage is placed in the distal 10mm of closed cervix or whose cervix fails to elongate subsequently, should remain under close surveillance as they have the highest risk of PTB.

Vaginal Cerclage: Preoperative, Intraoperative, and Postoperative Management

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention

Preterm birth remains a major cause of neonatal death and short and long-term disability in the US and across the world. The majority of preterm births are spontaneous and cervical length screening is one tool that can be utilized to identify women at increased risk who may be candidates for preventive interventions. The purpose of this document is to review the indications and rationale for CL screening to prevent preterm birth in various clinical scenarios. The Society for Maternal-Fetal Medicine recommends (1) routine transvaginal cervical length screening for women with singleton pregnancy and history of prior spontaneous preterm birth (grade 1A); (2) routine transvaginal cervical length screening not be performed for women with cervical cerclage, multiple gestation, preterm premature rupture of membranes, or placenta previa (grade 2B); (3) practitioners who decide to implement universal cervical length screening follow strict guidelines (grade 2B); (4) sonographers and/or practitioners receive specific training in the acquisition and interpretation of cervical imaging during pregnancy (grade 2B).

Factors associated with spontaneous preterm birth risk assessed by transvaginal ultrasound following cervical cerclage

OBJECTIVE

To determine the predictive value of various cervical length measurements postcerclage for the outcome of preterm birth following both elective and rescue cerclage.

MATERIALS AND METHODS

Over a five-year period, we identified 59 women who had a transvaginal cerclage inserted followed by serial cervical length measurement. Of these, 18 were elective cerclages placed at 14 weeks of gestation on the basis of a history of cervical insufficiency and 41 were rescue cerclages performed at gestations ranging from 17 to 23 weeks following a diagnosis of shortened cervix on ultrasound. The women were asymptomatic throughout.

RESULTS

There was a strong correlation between cervical length postcerclage and gestation at delivery. For both groups, preterm birth could be predicted by the total cervical length. In the rescue cerclage group, the change in cervical length was predictive, with positive changes associated with later gestation at delivery. The presence of funnelling was predictive of preterm birth in the elective cerclage group only.

CONCLUSION

Transvaginal cervical length measurement is useful in the prediction of preterm birth postcerclage placement. Serial cervical length measurement postcerclage may assist with timely addition of interventions such, progesterone and antenatal cortico steroids for fetal lung maturation.

[Prevention of obstetrical complications following LEEP, is it possible?]

Recent epidemiological data suggest an increase of the incidence and prevalence of CIN as well as a decrease of the mean age of the patients presenting these lesions. Large loop electrosurgical procedure (LEEP) is the most commonly used treatment method. According to recent studies LEEP provides a 1.4 to 7.0 fold increase of preterm delivery. Cervical cerclage does not show efficiency in reducing this risk, even if cervical shortening is measured by transvaginal ultrasound. Considering histological severity of lesions and the age of patients, number of currently conducted conizations in France could be avoided and so their obstetrical consequences prevented, just because no treatment is necessary or could be done by ablative procedures.

Transvaginal cervical cerclage: evidence for perioperative management strategies

The objective was to review the evidence supporting various perioperative technical and management strategies for transvaginal cervical cerclage. We performed MEDLINE, PubMed, EMBASE, and COCHRANE searches with the terms, cerclage, cervical cerclage, cervical insufficiency, and randomized trials, plus each technical aspect (eg, suture, amniocentesis, etc) considered. The search spanned 1966 through September 2012 and was not restricted by language. Each retrieved manuscript was carefully evaluated, and any pertinent references from the reports were also obtained and reviewed. All randomized trials covering surgical and selected perioperative, nonsurgical aspects of cerclage were included in the review. The evidence was assessed separately for history-, ultrasound-, and physical examination-indicated cerclage. Evidence levels according to the new method outlined by the US Preventive Services Task Force were assigned based on the evidence. There are no grade A high-certainty recommendations regarding technical aspects of transvaginal cervical cerclage. Grade B moderate-certainty recommendations include performing a fetal ultrasound before cerclage to ensure fetal viability, confirm gestational age, and assess fetal anatomy to rule out clinically significant structural abnormalities; administering spinal, and not general, anesthesia; performing a McDonald cerclage, with 1 stitch, placed as high as possible; and outpatient setting. Unfortunately, no other recommendations can be made regarding the other technical aspects of cerclage.

Is cerclage height associated with the incidence of preterm birth in women with an ultrasound-indicated cerclage?

OBJECTIVE

Our aim was to determine whether there was a cerclage height threshold associated with spontaneous preterm birth in patients with an ultrasound-indicated cerclage.

STUDY DESIGN

We performed a retrospective cohort study of women with an ultrasound-indicated cerclage. Functional cervical length and the cerclage height (distance from cerclage to the external cervical os) were obtained. Our cohort was grouped into thirds, based on cerclage height percentile. Our primary outcome was spontaneous preterm birth less than 35 weeks.

RESULTS

There were 20 women in group 1 (< 18 mm), 25 in group 2 (13-17 mm), and 25 in group 3 (> or = 18 mm). Women with cerclage height 18 mm or greater had a lower incidence of spontaneous preterm birth less than 35 weeks (4%) when compared with those with a cerclage height less than 18 mm (33%) (relative risk, 0.69; 95% confidence interval, 0.55-0.86).

CONCLUSION

Cerclage height of 18 mm or greater is associated with a reduction in spontaneous preterm birth for women with an ultrasound-indicated cerclage.

Pregnancy outcome after placement of 'rescue' Shirodkar cerclage

OBJECTIVE

Mid-trimester painless cervical dilation is associated with high rates of perinatal morbidity and mortality. 'Rescue' cerclage is one option in managing these patients. We evaluated pregnancy outcomes of women in whom we placed Shirodkar cerclage.

STUDY DESIGN

We analyzed the pregnancy outcome of a retrospective cohort of women carrying singleton pregnancies who experienced late mid-trimester cervical dilation in whom we placed Shirodkar cerclage. Exclusion criteria were uterine contractions, bleeding, premature rupture of membranes and chorioamnionitis. Primary outcomes were gestational age at delivery, maternal, fetal and neonatal outcomes and surgical complications.

RESULT

Between January 2003 and December 2005, 68 patients met our inclusion criteria. The average maternal age was 26.4+/-8.3 years and the mean gestational age at the time of surgery was 19.6+/-3.2 weeks. Seven women opted for expectant management and 5 more were followed up by their referring physicians; the 12 of them were used as a comparison group. Fifty-six women underwent placement of Shirodkar cerclage. We were unable to place a cerclage in three women (5.1%) and all three delivered before 23 weeks. Of the 56 women who had cerclage, 14 (23.7%) delivered at term, 20 (33.9%) delivered between 34 and 36.9 weeks, 13 (22%) between 30 and 33.9 weeks, 6 (10.2%) between 24 and 29.9 weeks and 3 (5.1%) before 24 weeks. Median time from diagnosis to delivery was longer in the cerclage group (9.1 weeks) than in the comparison group (3.3 weeks P<0.01).

CONCLUSION

When pregnancies are complicated by late mid-trimester cervical dilation, placement of Shirodkar cerclage in appropriately selected patients has the potential to be a beneficial therapeutic option.

Is there value for serial ultrasonographic assessment of cervical lengths after a cerclage?

OBJECTIVE

The objective of the study was to determine the value of serial ultrasonographic cervical length (CL) measurements after cerclage to predict preterm delivery.

STUDY DESIGN

Retrospective ultrasonographic and outcome data from singleton pregnancies with cerclage were reviewed. Using transvaginal ultrasound (TVS), overall CL obtained before cerclage placement, 2 weeks after cerclage, and before delivery were compared between women who delivered preterm (less than 37 weeks) and term. The overall CL including CL above (CLA) and below the cerclage (CLB) were compared using the SAS program.

RESULTS

Cerclage was placed at 15.7 +/- 3.6 weeks (mean +/- SD) in 57 women. The overall CL before cerclage, 2 weeks after cerclage, and the last TVS before delivery was not different in preterm and term births. The odds ratio of a measurable CLA for preterm delivery by TVS was 0.87 (0.78 to 0.95, 95% confidence interval). Thirty-two patients (56%) had absent CLA at 26.7 +/- 4.4 weeks. Of these, 16 (50%) were delivered for preterm premature rupture of membranes (PPROM) and chorioamnionitis (sensitivity of 100%, specificity of 61%, positive predictive value of 50%, and negative predictive value of 100%).

CONCLUSION

Although the overall cervical length by serial TVS after cerclage did not predict preterm birth, absent CLA is associated with preterm delivery, chorioamnionitis, and PPROM.

Tightening McDonald cerclage suture under sonographic guidance

OBJECTIVE

The technical factors contributing to failure of cerclage are not fully understood. The aims of this study were to assess the possibility of tightening the McDonald cerclage under ultrasound guidance and to examine the width and shape of the cervical canal before and after tightening the suture.

METHODS

A prospective study was performed. The sole indication for cerclage placement was clinical history of cervical insufficiency. Cervical length and canal width were measured by transvaginal ultrasound, at 12-14 weeks' gestation, with the patient's bladder empty, after which the cerclage was performed. Tightening of the suture was performed under sonographic guidance (transabdominal or transrectal) until the cervical canal disappeared from view. After tying the suture, cervical length and the canal width were assessed sonographically.

RESULTS

Fifty-eight patients were enrolled in the study; 50 patients had singleton pregnancies and eight patients carried twins. The mean cervical length at the beginning of the procedure was 31 +/- 13 mm (median 30 mm, range 15-48 mm). The mean cervical canal width was 2.1 +/- 0.9 mm (median 2.0 mm, range 0.9-4.5 mm). The mean addition to the length of the cervical canal after the procedure was 11 +/- 0.8 mm (median 1.0, range 8-19 mm). No complications were noted during the procedures. An interesting sonographic finding was an hourglass shape of the cervical canal after the procedure in 16 patients. Of 58 patients, 47 delivered at term, 10 delivered preterm and one miscarried at 18 weeks. Nine of 10 patients with preterm delivery had an hourglass-shaped sonographic appearance of the cervical canal after the procedure.

CONCLUSIONS

McDonald cerclage can be tightened under ultrasound guidance. The sonographic appearance of an hourglass shape of the cervical canal following suture tightening may be a risk factor for preterm delivery.

[What should you tell a patient with a history of cervical incompetence in the first trimester?]

Data is now more than ever available to inform couples at risk of second trimester miscarriage or preterm delivery. We are able to give customized information according to the obstetrical history and to the evolution of the cervix during the second trimester although the level of scientific evidence is limited or poor. Elective cerclage can be proposed to patients with a history of at least 3 second trimester miscarriages or preterm deliveries. There is no clear consensus on which patients could benefit from therapeutic cerclage. Indications would have to be motivated by a short cervix on ultrasound measurements and the cerclage performed before 24 weeks of gestation.

Does cerclage prevent preterm birth?

Cerclage procedures can be classified according to timing, (elective, urgent, emergent), and anatomic approach (transvaginal and transabdominal). The most current clinical data and the evidence-based recommendations for each type of cerclage procedure are listed.