Cervical Insufficiency and Cervical Cerclage

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Genetic Polymorphisms of COL1A1 Promoter Region (rs1800012) and TGFB1 Signal Peptide (rs1800471): Role in Cervical Insufficiency Susceptibility?

A structural or functional cervix problem prevents a woman from carrying a full-term pregnancy, which leads to the disease known as cervical insufficiency. Cervical insufficiency is partially inherited, and in certain situations, variations in genes related to connective tissue metabolism may be involved. The main objective of this investigation was to describe the collagen type I alpha 1 chain (COL1A1) gene rs1800012 polymorphism and the transforming growth factor beta 1 (TGFB1) gene rs1800471 polymorphism in a cohort of patients suffering from cervical insufficiency. Polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) assays have been used to analyze the DNAs of 93 patients with cervical insufficiency and 103 healthy controls. The chi-square test was used for statistical analysis. There were significant differences in the genotype frequencies of the COL1A1 gene rs1800012 (G > T) and TGFB1 gene rs1800471 (G > C) polymorphisms between the patient and the control groups (p = 0.049 and p = 0.049, respectively). Also, the C allele of the TGFB1 rs1800471 polymorphism was significantly higher in the patient group than the control group (p = 0.016). Following clinical assessment, the COL1A1 rs1800012 polymorphism was found to be connected to the history of cerclage (p = 0.010). Additionally, the frequency of the TT/GG composite genotype of COL1A1 rs1800012/TGFB1 rs1800471 polymorphisms was significantly lower in the patient group than the control group (p = 0.049). The TT genotype of COL1A1 rs1800012 polymorphism was found to be protective against cervical insufficiency, while the C allele of TGFB1 rs1800471 polymorphism was found to predispose to the disease. It appears that the TT/GG composite genotype of COL1A1 rs1800012/TGFB1 rs1800471 polymorphisms protects against cervical insufficiency.

Rescue Cervical Cerclage for Previable Birth Prevention: A Comprehensive Review of Indications, Techniques, and Outcomes

Cervical cerclage is a surgical intervention aimed at preventing previable birth by providing mechanical support to the cervix through the placement of a suture. This procedure is primarily indicated for cases of cervical incompetence, where the cervix is prone to premature dilation and can lead to early miscarriage or preterm birth. This review seeks to comprehensively analyze rescue cervical cerclage (RCC), focusing on its indications, techniques, and outcomes. The goal is to offer an in-depth understanding of its effectiveness in preventing previable birth and to guide clinical decision-making in managing pregnancies at risk of premature delivery. A thorough literature review examined recent studies and clinical data on RCC. Key aspects evaluated include the criteria for intervention, various surgical techniques employed, and the associated maternal and fetal outcomes. Comparative analysis was also performed with other preventive measures, such as progesterone therapy and bed rest. RCC has demonstrated efficacy in reducing the incidence of previable births, particularly when performed in cases of identified cervical incompetence or shortening. The review highlights variations in the technique, such as McDonald and Shirodkar cerclage, and discusses their relative success rates and potential complications. The procedure is associated with improved pregnancy outcomes and reduced risk of previable birth, though it carries some risks, including infection and cervical laceration. RCC remains a valuable intervention for preventing previable births in selected patients. This review underscores its importance in managing pregnancies at risk due to cervical incompetence and provides a detailed evaluation of its indications, techniques, and outcomes. Future research should optimize criteria for cerclage placement and explore novel strategies to enhance its effectiveness and safety.

The predictive value of hemogram parameters for early preterm delivery in pregnant women undergoing cervical cerclage

OBJECTIVE

This study aims to investigate the predictive value of hemogram parameters in early preterm delivery (32 gestational weeks and below) among pregnant women who have undergone cervical cerclage, based on cervical changes determined before the cerclage procedure.

METHODS

Between 2010 and 2020, a total of 161 patients underwent cervical cerclage. The participants were divided into three groups. Group 1 (n=92) consisted of pregnant women who underwent prophylactic cerclage. Group 2 (n=31) included those with cervical shortening (<5 mm) and/or dilation (≤3 cm). Group 3 (n=38) comprised pregnant women with cervical dilation >3 cm. Each group was further divided based on delivery weeks, with a cutoff at 32 weeks. Demographic parameters and laboratory parameters were assessed.

RESULTS

In Group 1, all hemogram parameters showed no significant differences between deliveries below and above 32 weeks. In Group 2, the neutrophil-to-lymphocyte ratio value before cerclage was higher in the early preterm delivery group (p=0.002), with a cutoff value of 4.75 in receiver operating characteristic analysis. In Group 3, the white blood cell value before cerclage was higher in the early preterm delivery group (p=0.005), with a cutoff value of 13.05×103/μL in receiver operating characteristic analysis.

CONCLUSION

The use of hemogram parameters to predict early preterm delivery in pregnant women undergoing prophylactic cerclage is not appropriate. However, neutrophil-to-lymphocyte ratio value can predict early preterm delivery when cervical dilation is 3 cm or less and/or cervical shortening is 5 mm or less. When cervical dilation exceeds 3 cm, the white blood cell value is more appropriate for predicting early preterm delivery.

Rescue Cervical Cerclage After 24 Weeks and Subsequent Childbirth After 34 Weeks of Gestation

A defect in the structure or function of the cervix that causes it to fail to contain the fetus intrauterine creates the condition called cervical insufficiency. Typical symptoms are pressure in the area of the pelvis, premature membrane rupture, and cervical dilation without uterine contractions. Surgical treatment includes the technique of cervical cerclage. It is usually performed from week 12 to week 16 of pregnancy. This article presents a case of rescue cervical cerclage after 24 weeks gestation and the observance of the pregnancy that followed. The cerclage was successful in prolonging the gestation of the fetus and no post-operative complications occurred due to the operation. The outcome of the pregnancy was a live and healthy baby born at 34 weeks gestation.

Noninvasive factors predicting the maintenance of pregnancy for more than 4 weeks after rescue cerclage in singleton pregnancies with cervical dilatation and prolapsed membrane

Studies on noninvasive factors and predicting the maintenance of pregnancy, and those comparing the usefulness of these factors with invasive amniotic fluid markers in predicting the maintenance of pregnancy following rescue cerclage, are lacking. Therefore, this study aimed to determine whether C-reactive protein (CRP) levels, White blood cell (WBC) count, absolute neutrophil count (ANC), and platelet-to-lymphocyte ratio (PLR) in maternal blood, which are noninvasive and readily available clinical markers, can predict the maintenance of pregnancy following rescue cerclage in patients with cervical insufficiency (CI). A total of 142 singleton pregnant women (15-28 wk) who underwent rescue cerclage for CI were retrospectively evaluated. The interleukin (IL)-6 concentration in the amniotic fluid; CRP levels, WBC count, ANC, and PLR in the maternal peripheral blood; and degree of cervical dilatation were evaluated before cerclage. The primary outcome was whether the pregnancy was maintained for >4 weeks after rescue cerclage. Among the 142 patients, prolonged pregnancy for >4 weeks following emergent cerclage was observed in 107 (75.35%), while 35 (24.65%) gave birth within 4 weeks. This study demonstrated that the degree of cervical dilatation at diagnosis; WBC count, ANC, and CRP levels in the maternal peripheral blood; and IL-6 concentration in the amniotic fluid significantly differed between the successful and failure groups (all P < .05). The area under the curve (AUC) of the amniotic fluid IL-6 concentration was .795 for the prediction of spontaneous preterm birth within 4 weeks after rescue cerclage. Additionally, the AUC of the CRP level, cervical dilatation, WBC count, ANC, and PLR were .795, .703, .695, .682, and .625, respectively. These findings suggest that the preoperative CRP levels can be considered a useful noninvasive marker comparable to amniotic fluid IL-6 concentration for identifying pregnant women with CI at high risk of spontaneous preterm birth following rescue cerclage.

Predictive value of serum inflammatory markers for histological chorioamnionitis among women with preterm premature rupture of membranes after undergoing cervical cerclage

PURPOSE

To determine the predictive value of maternal White Blood Cells (WBC), neutrophils, and C-Reactive Protein (CRP) for diagnosing Histological Chorioamnionitis (HCA) among women with Preterm Premature Rupture of Membranes (PPROM) who underwent cervical cerclage.

METHODS

A retrospective cross-sectional study was conducted among women with singleton pregnancy and PPROM, who underwent cervical cerclage during 2018-2020.

RESULTS

A total of 55 eligible women were included in the final analysis, including 36 (61.02%) cases with HCA and 19 (38.98%) without HCA. Women with HCA had higher WBC count (12.31 ± 2.80) × 109/L and neutrophil count (9.67 ± 2.90)×109/L than those without HCA (10.35 ± 2.53) × 109/L and 7.82 ± 2.82 × 109/L, respectively) (both p < 0.05). The cut-off value of WBC count at 10.15×109/L was found to be the most effective in identifying HCA, with an Area Under Curve (AUC) of 0.707 (95% CI: 0.56-0.86; p = 0.012), sensitivity of 86.11%, specificity of 57.90%, Positive Predictive Value (PPV) of 79.49%, Negative Predictive Value (NPV) of 68.75%, and Youden index of 0.44. The combination of WBC + neutrophil had a slightly higher (AUC = 0.711, 95% CI: 0.57-0.86; p = 0.011), specificity (68.42%), and PPV (81.25%), but lower sensitivity (72.22%), than the WBC count alone. A cut-off value of neutrophil at 7.46 × 109/L was effective in identifying HCA, with an AUC of 0.689 (95% CI: 0.53-0.84; p = 0.022).

DISCUSSION

Combination use of WBC+neutrophil was found to be the most accurate predictor of HCA among women with PPROM after surgery of cervical cerclage.

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

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

Abnormal Vaginal Flora in Cervical Incompetence Patients - the Impact of Escherichia coli

The purpose of this study was to investigate the prevalence of abnormal vaginal colonization in women with cervical incompetence and to analyze its impact on obstetric and neonatal outcomes and placental inflammation. We included 138 pregnant women diagnosed with cervical incompetence and delivered in our hospital. Patients with major fetal anomaly or multifetal pregnancy were excluded. Upper vaginal culture was performed on the day of admission. A total of 60.9% (84/138) of cervical incompetence patients had abnormal bacterial colonization, and Escherichia coli (E. coli) was the most common colonized pathogen (33.3%, 46/138). The positive vaginal E. coli group had a higher rate of prior preterm birth (p = 0.021) and an earlier gestational age at which cervical incompetence was diagnosed (p < 0.01) than the negative group. The positive vaginal E. coli group had higher rates of clinical chorioamnionitis (p = 0.008) and subchorionic microabscess of the placenta (p = 0.012). Importantly, the positive vaginal E. coli group had significantly higher rates of proven early-onset neonatal sepsis (EONS) (p = 0.046), necrotizing enterocolitis (NEC) (p = 0.001), and neonatal mortality (p = 0.023). After adjusting for confounding variables, the positive vaginal E. coli group had significantly higher risk for proven EONS (OR: 3.853, 95% CI: 1.056-14.055) and NEC (OR: 12.410, 95% CI: 1.290-119.351). In conclusion, E. coli was the most common vaginal microorganism isolated from patients with cervical incompetence. Maternal vaginal E. coli colonization was associated with adverse neonatal outcomes including proven EONS and NEC and was characterized by a higher rate of placental subchorionic microabscess.

Removal versus retention of cervical cerclage with preterm prelabor rupture of membranes: Systematic review and meta-analysis

OBJECTIVE

To evaluate maternal and perinatal outcomes of removal versus retention of cervical cerclage after premature preterm rupture of membranes (pPROM).

STUDY DESIGN

Medline, Embase and Cochrane databases were searched electronically on February 2023 utilizing combinations of the relevant medical subject heading (MeSH) terms, keywords, and word variants that were considered suitable for the topic. Either prospective or retrospective trials were considered suitable for the inclusion. The coprimary outcome of this study were pregnancy latency >7 days from pPROM and pregnancy latency >48 h from pPROM. Random effect head to-head meta-analyses were performed to directly compare each outcome, expressing the results as summary odds ratio (OR) for dichotomous outcomes and as mean difference (MD) for continuous outcomes, plus relative 95% confidence interval (CI). Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale.

RESULTS

Six studies involving a total of 377 women (169 in the "removal" and 208 in the "retention" group) were included. The rate of pregnancy prolongation >48 h was significantly lower in the removal compared to retention group (OR 0.15, 95% CI 0.07-0.31; p < 0.0001), as well as the rate of pregnancy prolongation >7 days (OR 0.30 95% CI 0.11-0.83; p = 0.02) and pregnancy latency expressed in days (MD -2.84 days, 95% CI -5.40 to -0.29; p = 0.03). The rate of chorioamnionitis was significantly lower in the removal compared to the retention group (OR 0.57 95% CI 0.34-0.96p = 0.03) as was the rate of Apgar score < 7 at 5 min (OR 0.22 95% CI 0.08-0.56; p = 0.002). There was no difference between removal and retention groups for all the other maternal and perinatal outcomes.

CONCLUSIONS

The decision whether to remove or retain cerclage in case of pPROM should balance the prematurity-related risks with that of infectious complications, thus highlighting the need for tailored management based on gestational age at occurrence of pPROM.

The Association of Inflammatory Markers with Maternal-Neonatal Outcome After Cervical Cerclage

Objective

Cervical cerclage is effective in prolonging the number of weeks gestation in patients with cervical insufficiency(CI). However, valuable predictors with successful cervical cerclage remain limited. It aimed to evaluate the value of the systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI) to predict the outcomes of cervical cerclage.

Methods

This study analyzed 374 participants. Inflammatory markers were calculated using maternal peripheral blood. The association of inflammatory markers and the outcome of cervical cerclage were analyzed. And the optimal cut-off values of inflammatory markers were calculated. Also, the Chi-square test and logistic and linear regression analyses were performed to evaluate inflammatory markers with the maternal outcome and neonatal outcomes.

Results

374 pregnancies were included in this study. Finally, 268 (71.7%) participants suffered successful cervical cerclage. This study demonstrated that the baseline BMI (cm²/kg), the bulging membrane, cervical dilation (≥2cm), the amniotic sac herniation, the neutrophils counts, the systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI) were significant difference between the successful and unsuccessful groups (all P<0.05). Additionally, maternal blood inflammatory markers, such as WBC, lymphocyte, neutrophils, monocyte, platelet counts, SII, and SIRI, were significantly associated with maternal-neonatal outcomes. Furthermore, the results demonstrated that the SII level had the highest OR (OR=4.626; 95% CI (2.500-8.560)), as well as the following: SIRI level (OR = 3.795; 95% CI (1.989-7.242)), cervical dilation (≥2cm) (OR =3.477; 95% CI (1.458-10.844)), and amniotic sac herniation (OR = 1.796; 95% (0.473-4.975)).

Conclusion

This study demonstrated that the baseline SII level and SIRI level are important biochemical markers for predicting the outcome of cervical cerclage and maternal-neonatal outcomes with non-invasive procedures. They can help to provide personalized treatment before surgery and enhance postoperative surveillance.

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.

Dynamic Change of Novel Systemic Inflammation Markers to Predict Maternal-Neonatal Prognosis After Cervical Cerclage

Objective

Cervical cerclage is an effective method to prevent preterm birth. However, the clinical indicators that can predict cervical cerclage remain limited. This study aimed to explore whether dynamically inflammatory markers are valuable biomarkers for the prognosis of cervical cerclage.

Methods

This study included 328 participants. Inflammatory markers were calculated using maternal peripheral blood before and after the cervical cerclage procedure. The Chi-square test, linear regression, and logistic regression were performed to evaluate the dynamic change of inflammatory markers with the prognosis of cervical cerclage. And the optimal cut-off values of inflammatory markers were calculated.

Results

Totally 328 pregnant women were analyzed in the study. 223 (67.99%) participants obtained successful cervical cerclage. This study revealed that the maternal age, the baseline BMI (cm²/kg), the times of gravida, the rate of recurrent abortion, the PPROM, cervical length shorter (<1.5cm), cervical dilation (≥2cm), the bulging membrane, the Pre-SII, the Pre-SIRI, the Post-SII, the Post-SIRI, and the ΔSII were significantly associated with outcomes after cervical cerclage (all P<0.05). Pre-SII, Pre-SIRI, Post-SII, Post-SIRI, and ΔSII levels were mainly related to maternal-neonatal outcomes. Furthermore, the results demonstrated that the ΔSII level had the highest OR (OR=14.560; 95% CI (4.461-47.518)). In addition, we revealed that Post-SII and ΔSII levels had the highest AUC (0.845/0.840) and relatively higher sensitivity/specificity (68.57/92.83% and 71.43/90.58%) and PPV/ NPV (81.82/86.25% and 78.13/87.07%) compared with other indicators.

Conclusion

This study suggested that the dynamic change of SII level and SIRI level are important biochemical markers to predict the prognosis of cervical cerclage and maternal-neonatal prognosis, especially the Post-SII and ΔSII levels. They can help to determine candidates for cervical cerclage before surgical procedure and enhance postoperative surveillance.

The Role of Amnioreduction in Emergency Cervical Cerclage with Bulging Membranes: A Retrospective Comparative Study

The purpose of this study was to investigate the role of amnioreduction in patients who underwent emergency cervical cerclage (ECC) with bulging membranes during the second trimester. This retrospective comparative study included 46 singleton pregnant women who had cervical dilation at least 1 cm with bulging membranes beyond the external cervical os and underwent ECC at the Third Affiliated Hospital of Sun Yat-sen University between December 2016 and December 2021. Cases were categorized as amnioreduction group (n = 16) and non-amnioreduction group (n = 30) according to whether amnioreduction was performed prior to ECC. The gestational age and cervical dilation at cerclage, operative time, prolongation of pregnancy, and outcomes of pregnancy were compared between the two groups. All 46 patients underwent successful ECC excepted one case with intraoperative rupture of membrane in non-amnioreduction group. In the amnioreduction group, the cervical dilation at cerclage was larger than that in the non-amnioreduction group (4.5 ± 2.2 vs. 2.2 ± 1.2 cm, P < 0.001), and had more patients with cervical dilation ≥4 cm (50.0% vs. 10.0%, P = 0.004). However, the gestational age at cerclage, operative time, prolongation of pregnancy, gestational age at delivery were not significantly different between the two groups (22.9 ± 2.8 vs. 22.9 ± 3.2 weeks, 31.1 ± 9.2 vs. 27.9 ± 11.4 min, 21.3 ± 21.5 vs. 38.7 ± 40.2 days, 25.9 ± 4.5 vs. 28.4 ± 6.1 weeks; P > 0.05). The rates of delivery ≥28 weeks, ≥32 weeks, and live birth were 20.0% vs. 80.0%, 12.5% vs. 26.7%, 56.3% vs. 66.7% (P > 0.05) in amnioreduction group and non-amnioreduction group, respectively. In conclusion, even in cases with larger cervical dilation, the application of amnioreduction with ECC is possible to get the acceptable pregnancy outcomes. These findings suggested that amnioreduction may be a safe and feasible option to be applied before ECC, especially for those with advanced cervical dilation and bulging membranes.

Outcome of Index Pregnancy in Women with Recurrent Pregnancy Loss (RPL)

Background

Recurrent pregnancy loss (RPL) is encountered in 2-5% of Obstetric population and in 50% the cause is unknown and hence it is a challenging situation for the Obstetrician to manage such women. This study was undertaken with the objectives of finding out the causes of RPL, comparing the outcome of index pregnancy between unknown RPL and known RPL and to study the pregnancy outcome with thromboprophylaxis in women with unknown RPL.

Methods

Prospective observational study involving 323 women was undertaken in a tertiary care Institute South India. Women with two or more pregnancy losses without any live birth were included after ethical clearance and were investigated including thrombophilia screening. SSPS version 20 was used for statistical analysis. Comparison of pregnancy outcomes was determined with binomial test of proportions and pregnancy outcome in unknown RPL was calculated by Fisher's exact test or Chi-square test.

Results

The common etiological factors were Thrombophilias (33%), followed by endocrine causes. There was no difference in miscarriage rates and live birth rates but IUGR, Stillbirth and perinatal deaths were significantly more in women with known RPL after interventions. In unknown RPL thromboprophylaxis with combination of aspirin, enoxaparin or progesterone resulted in significantly more term birth rates (93%).

Conclusion

Thrombophilias were found to be the most common cause in this cohort of Indian women. In women with unknown RPL, thromboprophylaxis with Aspirin alone results in high incidence of preterm birth. Aspirin combined with Enoxaparin and or Progesterone achieves high live birth rate of term foetuses.

Association of adherence to guidelines for cervical cerclage with perinatal outcomes and placental inflammation in women with cervical length ≥2.0 cm

OBJECTIVES

Cerclage operation is one of the most common obstetric controversies. The aim of this study was to compare the perinatal outcomes and placental inflammation of cerclage performed adherent and non-adherent to international guidelines.

MATERIAL AND METHODS

This study included all consecutive women with singleton deliveries who underwent cerclage. According to the current American College of Obstetricians and Gynecologists (ACOG) guideline, we designated our study population into two groups: the adherent-to-guideline and non-adherent groups. Each group was categorized into two groups according to cervical length (CL) at the time of cerclage (<2.0 cm vs. ≥2.0 cm). We evaluated the reasons for cerclage, maternal characteristics, perioperative variables, pregnancy and neonatal outcomes, and placental inflammatory pathology according to the criteria proposed by the Society of Pediatric Pathology.

RESULTS

Among 310 women with cerclage, we excluded patients (n = 21) with indicated preterm delivery (PTD), major fetal anomaly, fetal death in-utero, and missing information for reason of cerclage. We also excluded patients who underwent physical examination-indicated cerclage (n = 53) and with missing information of CL at the time of cerclage (n = 52). A total of 184 women were eventually analyzed. In women with CL < 2.0 cm, the non-adherent group showed similar PTD (<28 weeks, <34 weeks) and neonatal composite morbidity rates compared to the adherent-to-guideline group. However, in women with CL ≥ 2.0 cm, the non-adherent group manifested significantly higher PTD (<28 weeks; 16.7% vs. 4.4%, p = 0.04, <34 weeks; 23.8% vs. 5.8%, p = 0.006) and neonatal composite morbidity (20.5% vs. 5.9%, p = 0.028) rates than the adherent-to-guideline group despite similar perioperative variables and lower PTD history rates. The non-adherent group with CL ≥ 2 cm at the time of cerclage was also associated with severe histologic chorioamnionitis (p = 0.033).

CONCLUSION

Cerclage performed beyond the current guidelines in pregnant women with CL ≥ 2.0 cm may confer an additional risk of perinatal complications in association with severe placental inflammation.

COL1A1, COL4A3, TIMP2 and TGFB1 polymorphisms in cervical insufficiency

OBJECTIVES

To investigate the association between selected single nucleotide polymorphisms (SNPs) with cervical insufficiency and its relationship with obstetric history.

METHODS

Twenty-eight women with cervical insufficiency (case group) and 29 non-pregnant women (control group) were included. The SNPs sequenced included rs2586490 in collagen type I alpha 1 chain (COL1A1), rs1882435 in collagen type IV alpha 3 chain (COL4A3), rs2277698 in metallopeptidase inhibitor 2 (TIMP2), and rs1800468 in transforming growth factor beta 1 (TGFB1).

RESULTS

We found a higher frequency of the normal allele in the control group (65.5%) and the homozygous mutated genotype in the case group (64.3%) for rs2586490 in COL1A1 (p=0.023). An unplanned finding in the cervical insufficiency group was a higher gestational age of delivery (median≥38 weeks) in the mutated allele than in the wild-type genotype (median of 28.2 weeks) for rs2857396, which is also in the COL1A1 gene (p=0.011).

CONCLUSIONS

The findings of the present study corroborate the hypothesis that cervical insufficiency has a genetic component and probably involves genes encoding proteins in the extracellular matrix, in addition to inflammatory processes.

Guideline No. 401: Sonographic Cervical Length in Singleton Pregnancies: Techniques and Clinical Applications

OBJECTIVES

• To assess the association between sonography-derived cervical length measurement and preterm birth. • To describe the various techniques to measure cervical length using sonography. • To review the natural history of the short cervix. • To review the clinical uses, predictive ability, and utility of sonography-measured short cervix.

OUTCOMES

Reduction in rates of prematurity and/or better identification of those at risk, as well as possible prevention of unnecessary interventions.

INTENDED USERS

Clinicians involved in the obstetrical management or cervical imaging of patients at increased risk of a short cervix.

TARGET POPULATION

Women at increased risk of a short cervix or at risk of preterm birth.

EVIDENCE

Literature published up to June 2019 was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary and key words (preterm labour, ultrasound, cervix, cervical insufficiency, transvaginal, transperineal, cervical length, fibronectin). Results were restricted to general and systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date or language restrictions. Grey (unpublished) literature was identified through searching the websites of health technology assessment agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence and this guideline were reviewed by the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada, and the recommendations were made and graded according to the rankings of the Canadian Task Force on Preventive Health Care (Online Appendix Table A1).

BENEFITS, HARMS, COSTS

Preterm birth is a leading cause of perinatal morbidity and mortality. Use of the sonographic technique reviewed in this guideline may help identify women at risk of preterm birth and, in some circumstances, lead to interventions that may reduce the rate of preterm birth. SUMMARY STATEMENTS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES): RECOMMENDATIONS (CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE GRADING IN PARENTHESES).

Proteomic identification of biomarkers in maternal plasma that predict the outcome of rescue cerclage for cervical insufficiency

Objective

We sought to identify plasma protein biomarkers that are predictive of the outcome of rescue cerclage in patients with cervical insufficiency.

Methods

This retrospective cohort study included 39 singleton pregnant women undergoing rescue cerclage for cervical insufficiency (17–25 weeks) who gave plasma samples. Three sets of pooled plasma samples from controls (cerclage success, n = 10) and cases (cerclage failure, n = 10, defined as spontaneous preterm delivery at <33 weeks) were labeled with 6-plex tandem mass tag (TMT) reagents and analyzed by liquid chromatography-tandem mass spectrometry. Differentially expressed proteins between the two groups were selected from the TMT-based quantitative analysis. Multiple reaction monitoring-mass spectrometry (MRM-MS) analysis was further used to verify the candidate proteins of interest in patients with cervical insufficiency in the final cohort (n = 39).

Results

From MRM-MS analysis of the 40 proteins showing statistically significant changes (P < 0.05) from the TMT-based quantitative analysis, plasma IGFBP-2, PSG4, and PGLYRP2 levels were found to be significantly increased, whereas plasma MET and LXN levels were significantly decreased in women with cerclage failure. Of these, IGFBP-2, PSG4, and LXN levels in plasma were independent of cervical dilatation. A multiple-biomarker panel was developed for the prediction of cerclage failure, using a stepwise regression procedure, which included the plasma IGFBP-2, PSG4, and LXN (area under the curve [AUC] = 0.916). The AUC for this multiple-biomarker panel was significantly greater than the AUC for any single biomarker included in the multi-biomarker model.

Conclusions

Proteomic analysis identified useful and independent plasma biomarkers (IGFBP-2, PSG4, and LXN; verified by MRM) that predict poor pregnancy outcome following rescue cerclage. Their combined analysis in a multi-biomarker panel significantly improved predictability.

Prevention of preterm delivery by cervical cerclage; a comparison of prophylactic and emergency procedures

Objective:

Prophylactic or emergency type cervical cerclage procedures are being used for treatment of cervical insufficiency. The aim was to review and compare the outcomes of these cerclage types and identify factors affecting outcomes.

Material and Methods:

Retrospective review of seventy-five patients in whom transvaginal cervical cerclage procedures were performed over a seven-year period in a tertiary referral center.

Results:

Twenty seven of 75 (36%) patients were in the emergency cerclage group and 48 (64%) of them were in the prophylactic group. Mean body mass index (BMI), hospitalization time and gestational week at cerclage were significantly higher, whereas latency period was significantly shorter for the emergency group. Mean gestational ages at delivery were 35.6±4.5 and 33.6±5.9 weeks in the prophylactic and emergency groups, respectively (p=0.117). Delivery rates under 34^th gestational week were 20.8% and 37.0% in the prophylactic and emergency groups, respectively (p=0.175). Birthweight, and delivery ≥34^th gestational week was higher in the prophylactic group, whereas complication rate was higher in the emergency group, but these differences were not significant. High BMI was associated with more deliveries before 34-week in the prophylactic group. Pre-cerclage cervical length was shorter in patients who delivered before 34 gestational weeks at delivery.

Conclusion:

Prophylactic and emergency cerclage procedures have comparable results regarding gestational week at delivery. High BMI and low pre-cerclage cervical length may have adverse effects on success of cerclage procedures.

Fertility-sparing treatment in cervical cancer: Abdominal trachelectomy

In the last two decades, great strides have been made to treat cancer while sparing fertility for young women. This is at least partly in response to changing demographics, including delayed childbearing and fewer historically traditional couples. The trachelectomy has become emblematic in this endeavor. With comparable outcomes to hysterectomy and successful conceptions, trachelectomy utilization has increased over time. It is now a standard of care for many situations. While there are several approaches, (vaginal, laparoscopic, and robotic), the abdominal trachelectomy allows surgeons to overcome several limitations, such as patient anatomy, surgical experience, and resources (i.e. no robot) to provide women everywhere this revolutionary operation. In this chapter, we outline surgical techniques, outcomes, and other aspects of the abdominal trachelectomy.

The prevalence of cervical insufficiency in Chinese women with polycystic ovary syndrome undergone ART treatment accompanied with negative prognosis: a retrospective study

The objective of this study was to explore the correlation between cervical insufficiency (CI) and polycystic ovary syndrome (PCOS) in Chinese women undergoing assisted reproductive technology (ART) treatment. The retrospective study enrolled 2978 women including 1489 with PCOS and 1489 without PCOS, among which 34 women were diagnosed with CI (1.14%). The prevalence of CI in PCOS women was statistically higher than that in women without PCOS. Among those women with CI, 23 cases exhibited PCOS, and those cases had an average gestational age of 26.09 ± 5.91 weeks at the end of pregnancy, which was earlier than that of women without PCOS, and the pregnancy outcomes were worse than in the non-PCOS group though not statistically significant. Multivariable logistic regression showed that PCOS status (odds ratio: 2.050, 95% confidence interval: 1.009-4.206) were associated with increased risk of CI. Our study revealed that among those Chinese women who conceived by ART treatment, the prevalence of CI in women with PCOS was higher than that in women without PCOS. Co-morbidity of CI with polycystic ovarian syndrome negatively impacts prognosis.Impact statementWhat is already known on this subject? Women with PCOS have a higher rate of adverse obstetrical outcomes than women without PCOS.What the results of this study add? Women with PCOS were more likely to have pregnancies complicated with CI. Co-morbidity of cervical incompetence with PCOS negatively impacts prognosis.What the implications are of these findings for clinical practice and/or further research? Given these results, close surveillance of cervical changes during the second trimester in women with PCOS is necessary for reducing the risk of miscarriage related to CI.

Pregnancy outcomes and factors affecting the clinical effects of cervical cerclage when used for different indications: A retrospective study of 326 cases

OBJECTIVE

To compare pregnancy outcomes resulting from the use of cervical cerclage for different indications and investigate factors that might influence the clinical effects of cervical cerclage.

MATERIALS AND METHODS

This was a retrospective study of pregnant women who received cervical cerclage in The Women's Hospital, Zhejiang University School of Medicine, China. Patients were divided into three groups: a history-indicated group; an ultrasound-indicated group and a physical examination-indicated group. The pregnancy outcomes of the three groups were then compared. Univariate and multivariate logistic regression analysis were performed to assess the independent risk factors.

RESULTS

Statistical differences were evident when the history-indicated group and the ultrasound-indicated group were compared with the physical examination-indicated group for gestational age at delivery [37.3(33.3-38.9), 35.4(28.9-38.4) vs. 26.1 (24.3-28.4) weeks, respectively, P < 0.05], percentage of cases delivered at < 28 weeks of gestation (13.4%, 20.3% vs. 74.3%, respectively, P < 0.05), percentage of cases delivered at < 37 weeks of gestation (42.7%, 54.2% vs. 91.4%, respectively, P < 0.05) and fetal survival rate (88.4%, 81.4% vs. 40.0%, respectively, P < 0.05). The history-indicated group and the ultrasound-indicated group were similar with regards to these outcomes. The independent risk factors affecting the clinical effects of cervical cerclage include age, body mass index (BMI), history of prior preterm birth and second-trimester loss, C-reactive protein (CRP) >5 mg/L and cervical dilation ≥3 cm (P < 0.05).

CONCLUSION

Pregnancy outcomes were similar when compared between history-indicated and ultrasound-indicated cerclage. Serial cervical surveillance is beneficial for pregnant with a history of cervical insufficiency, and the placement of cervical cerclages in response to ultrasonographically detected shortening of the cervical length is a medically acceptable alternative to the use of history-indicated cerclage.

The impact of funneling shape on the secondary prevention of spontaneous preterm birth in patients treated with either an Arabin pessary, McDonald cerclage or early total cervical occlusion (ETCO)

OBJECTIVE

Cervical funneling is associated with spontaneous preterm birth (sPTB). The aim of this analysis was to assess the relationship between funneling shape and the response to the McDonald cerclage, the Arabin pessary and the early total cervical occlusion (ETCO).

METHODS

We retrospectively analyzed data of 312 randomly selected singleton pregnancies with cervical shortening <25 mm or normal cervical length and evaluated them according to the progression of funneling: control group (n = 46), cervical shortening without funneling (n = 107), V-shaped funneling (n = 68), U-shaped funneling (n = 47), and prolapse of the amniotic sac (n = 44). We evaluated sPTB rates <34, <28, <32, and <37 weeks as well as prolongation of gestation and birthweight.

RESULTS

Regarding the rate of sPTB <34 weeks there was no statistical significance in either of the comparisons between control group and each of the four risk groups. Regarding prolongation of gestation we demonstrated a statistical significance for all risk groups compared to the control group (all p < .05) with the lowest prolongation rate noted in the group with amnion prolapse and the highest in the group with isolated cervical shortening without funneling. Similarly, progression of funnel shape resulted in an absolute decrease of birthweight for all risk groups compared to the control group, albeit not significant for the group with U-shaped funneling (p = .1058).

CONCLUSION

Independent of the treatment, there was a significant impact of funneling shape on pregnancy duration and birthweight.

Factors associated with preterm birth in women undergoing cervical cerclage

OBJECTIVES

Cervical cerclage is used to manage women at high risk of late miscarriage (LM) and spontaneous preterm birth (PTB) due to factors such as history of cervical insufficiency (CI), uterine anomaly, cervical surgery and ultrasound (US) diagnosed cervical shortening. Urinary tract infection (UTI) and subsequent pyelonephritis, and bacterial infection are associated with PTB, but their role in PTB after cervical cerclage is unknown. We examined the relationship between UTI and bacterial vaginosis (BV), fetal fibronectin (fFN) test and PTB in women undergoing elective- or US-indicated cervical cerclage. We also investigated whether fetal fibronectin (fFN) test were useful to predict PTB.

STUDY DESIGN

This is a single center, retrospective study of singleton pregnant women at PTB clinic, University College London Hospital (UCLH, 2005-2015) who underwent elective or US-indicated cervical cerclage. Women were tested for UTI and BV before cerclage placement and received mid-gestation fFN testing. Patient data were extracted from the PTB clinic database and electronic records. Statistical analyses used Pearson's chi-square and Mann-Whitney U tests. P values were corrected by Bonferroni method as required.

RESULTS

267 singleton pregnant women attended our clinic with completed birth outcome. Of those, 32.2% (86/267) delivered prematurely. All women with UTI or BV received antibiotic treatment. Women with a UTI before cerclage placement were more likely to deliver preterm when compared to those with negative MSU culture (OR 3.39, 95%CI 1.24-9.27, p = 0.04). Their gestational age at delivery were also lower than those with negative MSU result (36⁺⁶, IQR 31⁺⁴-38⁺²week vs 38⁺¹, IQR 36⁺¹-39⁺⁵-week, p = 0.05). However, UTI after cerclage placement or BV either before or after cerclage placement were not associated with PTB. Women who had a positive fFN result were more likely to deliver preterm (OR 3.85, 95% CI 1.81-8.41, p = 0.0007).

CONCLUSIONS

The presence of a UTI before cervical cerclage is associated with a higher rate of PTB in women who receive a cervical cerclage, even when treated. We did not find an association between pre or post-cerclage BV or post-cerclage UTI and PTB. Further research is needed to elucidate the link between UTI and PTB in women undergoing cervical cerclage.

CERVICAL INSUFFICIENCY: CLASSIFICATION, ETIOPATHOGENESIS, DIAGNOSIS, METHODS OF PROPHYLAXIS AND CORRECTIONS (CLINICAL LECTURE)

Тhe clinical lecture presents modern views on the problem of cervical insufficiency and its role in the miscarriage. Etiological agents of the cervical insufficiency development, its classification, diagnostic and differential diagnosis with short cervix have been reviewed. Particular attention has been drawn to the role of progesterone, microelements and connective tissue for development and progress of the mentioned pathology. The historical aspect was applied both for methods of possible treatments and prophylaxis of the cervical insufficiency and for advanced surgical and conservative correction. The algorithm of the obstetric actions for the cervical insufficiency is proposed.

MODERN TREATMENTS FOR PCOS (LITERATURE REVIEW)

According to world statistics, polycystic ovary syndrome (PCOS) is one of the most common forms of endocrinopathy in women of mainly reproductive age. PCOS can cause metabolic dysfunction, ovulatory infertility, endometrial cancer, pre- mature birth, perinatal mortality, and other serious consequences. The article discusses various methods of conservative and surgical treatment of PCOS. The main focus is on conservative treatment of infertility caused by PCOS.

The Identification of Immune-Related Plasma Proteins Associated with Spontaneous Preterm Delivery and Intra-Amniotic Infection in Women with Premature Cervical Dilation or an Asymptomatic Short Cervix

BACKGROUND

We aimed to investigate whether various immune-related plasma proteins, alone or in combination with conventional clinical risk factors, can predict spontaneous preterm delivery (SPTD) and intra-amniotic infection in women with premature cervical dilation or a short cervix (≤ 25 mm).

METHODS

This retrospective study included 80 asymptomatic women with premature cervical dilation (n = 50) or a short cervix (n = 30), who underwent amniocentesis at 17-29 weeks. Amniotic fluid (AF) was cultured, and maternal plasma was assayed for interleukin (IL)-6, matrix metalloproteinase (MMP)-9, tissue inhibitor of metalloproteinases (TIMP)-1, and complements C3a and C5a, using enzyme-linked immunosorbent assay (ELISA) kits. The primary outcome measures were SPTD at < 32 weeks and positive AF cultures.

RESULTS

The plasma levels of IL-6, C3a, and C5a, but not of MMP-9 and TIMP-1, were significantly higher in women with SPTD at < 32 weeks than in those who delivered at ≥ 32 weeks. The women who delivered at < 32 weeks had more advanced cervical dilatation, and higher rates of antibiotic and tocolytic administration and were less likely to be given vaginal progesterone than those who delivered at ≥ 32 weeks. Using a stepwise regression analysis, a combined prediction model was developed, which included the plasma IL-6 and C3a levels, and cervical dilatation (area under the curve [AUC], 0.901). The AUC for this model was significantly greater than that for any single variable included in the predictive model. In the univariate analysis, plasma IL-6 level was the only significant predictor of intra-amniotic infection.

CONCLUSION

In women with premature cervical dilation or a short cervix, maternal plasma IL-6, C3a, and C5a levels could be useful non-invasive predictors of SPTD at < 32 weeks. A combination of these biomarkers and conventional clinical factors may clearly improve the predictability for SPTD, as compared with the biomarkers alone. An increased plasma level of IL-6 predicted intra-amniotic infection.

Rescue Cervical Cerclage : Prevention of a Previable Birth

Rescue cervical cerclage can effectively prolong a nonviable gestation to viability, if done correctly in chosen patients after appropriate counseling. Here, we present a case study of an antenatal woman with advanced cervical changes at 24 weeks who benefited from the rescue cervical cerclage procedure to have a successful pregnancy outcome.

Proteomic Analysis of Amniotic Fluid Proteins for Predicting the Outcome of Emergency Cerclage in Women with Cervical Insufficiency

We aimed to identify novel biomarkers in amniotic fluid (AF) that predict the outcome of emergency cerclage in women with cervical insufficiency. This retrospective cohort study included 40 singleton pregnant women who received emergency cerclage for cervical insufficiency (17-25 weeks) and underwent amniocentesis. Label-free liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to identify AF proteins in pooled samples (n = 16) using a nested case-control approach. The six candidate biomarkers of interest were validated by enzyme-linked immunosorbent assays (ELISA) in the final cohort (n = 40). The differentially expressed proteins (DEPs) were analyzed by pathway analysis software. The primary outcome measure was failure of emergency cerclage [defined as spontaneous preterm delivery (SPTD) at < 34 weeks of gestation after cerclage placement]. Sixty-eight proteins were differentially expressed (P < 0.001) in AF from SPTD cases and near-term controls, of which 44 (64.7%) were upregulated and 24 (35.3%) were downregulated. Validation by ELISA confirmed that AF from women with cerclage failure contained significantly higher levels of myeloperoxidase, lactoferrin, glucose-6-phosphate isomerase, lipocalin-2, and lymphocyte cytosolic protein 1, the first four of which were independent of cervical dilatation at presentation. The five pathways with the most differentially regulated proteins were actin cytoskeleton signaling, acute phase response signaling, ILK signaling, glycolysis, and gluconeogenesis. Proteomic analyses of AF in this study identified DEPs and specific protein pathways related to poor prognosis after emergency cerclage for cervical insufficiency. Four novel independent biomarkers in AF for cerclage failure have been identified using proteomics.

Interval laparoscopic transabdominal cervical cerclage (ILTACC) using needleless mersilene tape for cervical incompetence

Interval Laparoscopic Transabdominal Cervical Cerclage (ILTACC) has become a procedure of choice for many laparoscopic surgeons in nonpregnant patients diagnosed with cervical incompetence (CI) due to the inherent advantages it offers. The study was conducted to describe the feasibility of performing a three-step approach of ILTACC using a needleless mersilene tape in patients diagnosed with CI. A case series of three patients diagnosed with CI who underwent ILTACC using needleless mersilene tape referred at a tertiary hospital for cerclage. Women diagnosed with CI who underwent ILTACC using a needleless mersilene tape were included in the study, and surgical outcomes were measured. Descriptive statistics were used to describe the demographic profile and surgical outcomes of the patients. Three patients with a mean age of 31 (standard deviation [SD] = 4.96) years with a gravidity of 2.67 (SD, 0.82) and parity of 0.33 (SD, 0.47) were selected. The cervical length was 1.98 (SD, 0.76) cm. The average operative time was 149 (SD, 43.87) minutes. All patients had minimal blood loss (≤ 60 ml) without intraoperative blood transfusion. The hospital stay was 1.33 (SD, 0.47) days with a median of 1 and a range of 1–2 days. No intraoperative or postoperative complications were noted. No cases were converted to laparotomy. The result of this article shows the safety and feasibility of ILTACC using needleless mersilene tape. However, it should be evaluated in more cases.

Knot positioning during McDonald cervical cerclage, does it make a difference? A cohort study

Objective: To study the effect of McDonald cerclage knot position on the different maternal and neonatal outcomes. Methods: This historical cohort study included women with singleton pregnancy who had a prophylactic McDonald cervical cerclage between 1 May 2010 and 31 September 2017. Maternal and neonatal outcome parameters were compared between the anterior and posterior knot cerclage procedures. The primary outcome measure was the rate of term birth. Results: 550 Women had a prophylactic McDonald cervical cerclage, 306 with anterior knot (Group A) and 244 with posterior knot (Group B). There were no statistically significant differences regarding gestational age (GA) at delivery (36.3 ± 4.2 versus 35.8 ± 5.3 for groups A and B respectively), term birth rate, post-cerclage cervical length, symptomatic vaginitis, urinary tract infection, difficult cerclage removal and cervical lacerations. Similarly, there were no statistically significant differences as regards the studied neonatal outcomes including take home babies, neonatal intensive care admission, respiratory distress syndrome and neonatal sepsis. Survival analysis on GA at delivery demonstrated no statistically significant difference as regards the proportion of term deliveries in the anterior and posterior knot cerclage groups (log-rank test p-value = .478). Conclusions: Knot positioning during McDonald cervical cerclage, anteriorly or posteriorly, didn't significantly impact the studied maternal and neonatal outcomes.

History-indicated cervical cerclage in management of twin pregnancy

OBJECTIVE

Cervical cerclage, when performed in twin gestation, has been reported to be associated with poor outcome. However, the role of first-trimester history-indicated cerclage among women with a twin pregnancy and a history of preterm birth has not been evaluated. The aim of this study was to assess pregnancy outcomes among women with a twin pregnancy who underwent first-trimester history-indicated cervical cerclage compared with outcomes in those managed expectantly.

METHODS

This was a retrospective matched case-control study. The study group comprised all women with a twin pregnancy who had undergone first-trimester history-indicated cerclage during the period 2006 to 2017 at Hadassah-Hebrew University Medical Center. A control group of women with a twin pregnancy who were managed expectantly was established by matching age, history of spontaneous preterm birth (20-36 weeks' gestation) and year of delivery. Pregnancy and delivery characteristics and neonatal outcomes were compared between the two groups.

RESULTS

Data from 82 women with a twin gestation were analyzed, of whom 41 underwent first-trimester history-indicated cerclage and 41 were matched controls who were managed expectantly. Gestational age at delivery was higher in the cerclage group than in those managed expectantly (median 35 vs 30 weeks; P < 0.0001). Rates of spontaneous preterm birth before 24 weeks (2.4% vs 19.5%; odds ratio (OR), 0.10 (95% CI, 0.01-0.87); P = 0.03), before 28 weeks (12.2% vs 34.1%; OR, 0.27 (95% CI, 0.09-0.84); P = 0.03), before 32 weeks (22.0% vs 56.1%; OR, 0.22 (95% CI, 0.08-0.58); P = 0.003) and before 34 weeks (34.1% vs 82.9%; OR, 0.11 (95% CI, 0.04-0.30); P < 0.0001) were significantly lower in the cerclage group than in the control group. Median birth weight was higher in the cerclage group (2072 g vs 1750 g; P = 0.003), with lower rates of low birth weight (< 2500 g) (65.0% vs 89.4%; P = 0.001) and very low birth weight (< 1500 g) (21.3% vs 37.9%; P = 0.03) than in the group managed expectantly. Rates were also lower in the cerclage group for stillbirth, admission to the neonatal intensive care unit, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal mortality and composite adverse neonatal outcome.

CONCLUSIONS

History-indicated cerclage performed in the first trimester, as compared with expectant management, in women with a twin pregnancy had an overall positive effect on pregnancy and neonatal outcomes. These findings suggest the need for adequate randomized trials on cerclage placement in this subset of women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Perinatal Outcomes After Emergency Cervical Cerclage for Cervical Insufficiency with Prolapsed Membranes

Background

To study the clinical effective of emergency cervical cerclage (ECC) in pregnant women who have cervical insufficiency with prolapsed membranes.

Material/Methods

This study was devised as a retrospective cohort in a single medical center, in which we collected clinical data from patient records. Inclusion criteria were: physical examination indicated ECC was performed at 15 to 25 gestational weeks at the Sixth Medical Center of the PLA General Hospital, and singleton pregnancy. The collected clinical data included: duration of pregnancy at delivery, interval between ECC and delivery, neonatal weight, neonatal mortality, neonatal morbidity, and Neonatal Intensive Care Unit (NICU) admission.

Results

We included 50 women with singleton pregnancies. No surgical complications occurred in any patients. The gestational age at cerclage was 21.3±2.2 weeks. No patients had membrane damage due to surgery. No surgical complications were reported. Five (10%) patients underwent chorioamnionitis. The time interval between ECC and delivery was 11.2±7.1 weeks. The mean gestational age at delivery was 34.1 weeks. The rate of vaginal delivery was 96%. Ten patients had pregnancy lasting longer than 36 weeks. The mean neonate delivery weight was 2510.7 g. Twenty neonates were admitted to the Neonatal Intensive Care Unit (NICU), and the mean NICU stay was 21 days.

Conclusions

ECC has good perinatal results. Our results provide clinical evidence for the efficacy and risks of ECC.

Adjuvant 17-hydroxyprogesterone caproate in women with history-indicated cerclage: A systematic review and meta-analysis

INTRODUCTION

The purpose of this study was to evaluate whether there are additional benefits of 17-hydroxyprogesterone caproate (17-OHPC) supplementation in preventing recurrent spontaneous preterm birth in women with a prophylactic cerclage.

MATERIAL AND METHODS

Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, Scielo and the Cochrane Central Register of Controlled Trials) were searched for studies published before June 2018. Keywords included "preterm birth", "prophylactic cerclage", "history-indicated cerclage", "pregnancy" and "17-hydroxyprogesterone caproate". Studies comparing history-indicated cerclage alone with cerclage+17-OHPC were included. The primary outcome measure was preterm birth at <24 weeks of gestation. Secondary outcome measures include preterm birth at <28 weeks, <32 weeks and <37 weeks of gestation, respiratory distress syndrome, necrotizing enterocolitis, fetal birthweight, neonatal intensive care unit stay, mean gestational age at delivery, fetal/neonatal death, neurological morbidity (intraventricular hemorrhage plus periventricular leukomalacia), neonatal sepsis and a composite of severe neonatal morbidity. Severe neonatal morbidity was defined as a composite measure of periventricular leukomalacia, intraventricular hemorrhage (grades III and IV), necrotizing enterocolitis or respiratory distress syndrome. Meta-analysis was performed using the random-effects model of DerSimonian and Laird. Risk of bias and quality assessment were performed using the ROBINS-I and GRADE tools, respectively. PROSPERO Registration Number: CRD42018094559.

RESULTS

Five studies met the inclusion criteria and were included in the final analysis. Of the 546 women, 357 (75%) received history-indicated cerclage alone and 189 (35%) received adjuvant 17-OHPC. The composite endpoint, severe neonatal morbidity, was present in 84 of 1515 neonates. Though there was a trend toward a reduced risk of preterm birth, the summary estimate of effect was not statistically significant when comparing cerclage alone with cerclage+17-OHPC at <24 weeks (relative risk [RR] .86, 95% confidence interval [CI] .45-1.65). Similarly, we found no differences in preterm birth at <37 weeks (RR .90, 95% CI .70-1.17) and <28 weeks (RR .85, 95% CI .54-1.32) when comparing cerclage alone with cerclage+17-OHPC. There were no differences in fetal birthweight, respiratory distress syndrome or necrotizing enterocolitis comparing cerclage alone with cerclage+17-OHPC.

CONCLUSIONS

Intramuscular 17-OHPC in combination with prophylactic cerclage in women with prior preterm birth had no synergistic effect in reducing spontaneous recurrent preterm birth or improving perinatal outcomes.

Emergency versus Elective Cervical Cerclage: An Audit of Our First Two Years of Service

One of the biggest obstetric challenges is the diagnosis and management of a short cervix as cervical length has an inverse relationship with risk of preterm birth. A cervical cerclage is a surgical procedure to reduce the risk of preterm birth and can be placed in an elective or emergency setting. This is a retrospective review of cervical cerclages inserted at an outer metropolitan hospital from February 2014 to May 2017. Since the introduction of the service, a total of 43 patients were identified as requiring a cervical cerclage. Four of these patients were transferred to tertiary hospitals. Of the 39 cerclages inserted, 26 were elective and 13 were emergency, placed at a mean gestation of 15.6 and 19.6 weeks. In total, there were 35 live births, 2 stillbirths, and 2 neonatal deaths. The maternal demographics (age, gravidity, parity, and preterm risk factors) were not statistically significant between the two groups. The mean pregnancy prolongation and birthweight was greater in the elective than the emergency group (21.4 versus 14.1 weeks; 3148.2 versus 2447.2 grams). There was no obvious pattern with which patients received antibiotics pre-, intra-, or postoperatively or received a vaginal swab. This audit identified the need for improvements to guidelines to standardise the use of antibiotics and progesterone in women with a cervical cerclage.

Outcomes of physical examination-indicated cerclage in twin pregnancies with acute cervical insufficiency compared to singleton pregnancies

Objectives To compare pregnancy outcomes of physical examination-indicated cerclage in twin pregnancies with acute cervical insufficiency with that of singletons. Methods This retrospective cohort study included 88 consecutive women (17 twins and 71 singletons) who had undergone physical examination-indicated cerclage because of acute cervical insufficiency (defined as painless cervical dilation with (1) prolapsed and/or visible membranes at the external cervical os on speculum examination and (2) a functional cervical length of zero on transvaginal ultrasound) between 160/7 and 236/7 weeks. The primary outcome measure was preterm delivery <34 weeks. Results (1) The frequency of preterm delivery <34 weeks was not significantly different between the two groups [twins, 56% (9/16) vs. singleton, 53% (37/70), P>0.999]. (2) The perinatal mortality was 21% (7/34) in twins and 32% (23/71) in singletons. (3) The median gestational age at delivery for twin pregnancies was 31.0 weeks (IQR, 22.6-36.5 weeks), which was similar to that of singleton pregnancies (median 32.4 weeks; IQR 22.3-38.3 weeks). (4) There were no significant differences in preterm delivery before 28 and 32 weeks, interval from cerclage to delivery within 1, 2, 4 and 8 weeks and neonatal morbidities between the two groups. Conclusion The obstetric and neonatal outcomes of physical examination-indicated cerclage in twin pregnancies were comparable to those in singleton pregnancies.

Amniotic fluid proteomic signatures of cervical insufficiency and their association with length of latency

PROBLEM

Cervical insufficiency is a precursor of preterm birth. Treatment with emergency cervical cerclage is contraindicated in the presence of intra-amniotic infection. Detecting infection with Gram stain and culture of amniotic fluid lacks sensitivity. Proteomic profiling of amniotic fluid in cervical insufficiency may help identify pregnancies best suited for emergency cerclage.

METHOD OF STUDY

Thirty-two pregnant women underwent amniocentesis for routine genetic testing (n = 22) or after diagnosis of cervical insufficiency (n = 10). The proteomic profiles of the amniotic fluid samples were compared in a cross-sectional fashion, including sub-analyses of women with cervical insufficiency and latency periods of <1 week and >1 week post-diagnosis.

RESULTS

Mean gestational age at diagnosis of cervical insufficiency was 21.4 weeks (95% CI 20.6-22.1). Proteomic analysis yielded 40 (7.2%, P < 0.05) differentially expressed proteins between women with delivery <1 week (n = 6) vs. >1 week (n = 4). Women who delivered <1 week had activated inflammatory response (z = 2.3, P = 6.71E-09), chemotaxis of immune cells (z = 2.9, P = 2.01E-08), and inhibited bacterial growth (z = -2.2, P = 5.82E-05). A multivariate model of eight biomarkers positively associated with cases of <1 week latency and distinguished cases from controls (97.8%, cross-validation accuracy 92.7%, P = 0.0009).

CONCLUSION

In this pilot study, significant differences in the amniotic fluid proteomic profiles in cases of cervical insufficiency compared to genetic amniocentesis were observed. Proteomic signatures were predictive of achieving latency > 1 week after diagnosis of cervical insufficiency. These preliminary findings suggest that proteomic analysis may be of value in predicting outcome following cervical insufficiency and warrants further validation in larger studies.

Laparoscopic cervico-isthmic cerclage: About 25 cases

INTRODUCTION

The purpose of this study is to report on our experience of laparoscopic cervico-isthmic cerclage.

MATERIAL AND METHOD

A monocentric retrospective study covering a 13-year period during which 25 cases of laparoscopic cerclage outside of pregnancy were performed, using the technique described by Dubuisson, at the University Hospital of Clermont-Ferrand. Individual patient data included pregnancy outcomes before and after cerclage and the characteristics of surgery.

RESULTS

The mean age of the patients was 33.9 (±4.6) years. A total of 68 pregnancies were recorded before cerclage, including 31 late miscarriages, 11 premature deliveries, with only 9 pregnancies attaining full-term. The average time of surgery was 54 (±17.5) minutes with a hospital stay of 24h. 3 minor intraoperative complications (12%) with hemorrhage <300cc were noted and managed intraoperatively. In some cases laparoscopy allowed treatment of associated pathologies (septum resection, adhesiolysis, endometriosis, ovarian drilling, tube assessment). 21 pregnancies (68% of patients) were recorded post cerclage including 5 early miscarriages and 16 cesarean deliveries with an average time taken to conceive of 11.8 months. The overall neonatal survival rate after cerclage was 76.2% versus 16.20% before surgery (p<0.0001), with a 100% neonatal survival rate beyond the 1st trimester as compared to 21.6% before cerclage (p<0.0001).

Pregnancy outcomes and superiorities of prophylactic cervical cerclage and therapeutic cervical cerclage in cervical insufficiency pregnant women

PURPOSE

To compare the clinical effect of prophylactic cervical cerclage and therapeutic cervical cerclage on pregnancy outcome and operative factors in cervical insufficiency pregnant women.

METHODS

A retrospective study was conducted between June 2014 and September 2016 in a maternity ward, which included women who have had a single pregnancy and have been carried out a McDonald cerclage. All maternal medical records were reviewed. The efficacy of cerclage for preventing late foetal loss was assessed using multivariable logistic regression analysis.

RESULTS

The results showed that there were significant associations between cerclage operations and pregnancy outcomes in the duration of pregnancy prolongation in terms of live births, gestation age, live birth and cesarean section rate. In prophylactic cervical cerclage, compared with therapeutic cervical cerclage, cervical length before surgery was significantly longer (32.7 ± 5.8 vs 19.9 ± 7.3 mm, p < 0.0001). Mean operative duration and postoperative length of hospital stay in prophylactic cervical cerclage were shorter than those in therapeutic cervical cerclage (22.1 ± 10.3 vs 28.9 ± 13.0 min, p = 0.0241 and 5.6 ± 1.8 vs 7.0 ± 2.8 days, p = 0.0354), respectively. Compared with therapeutic cerclage, prophylactic cerclage had more advantages in gestational age at delivery (35.2 ± 5.5 and 31.7 ± 6.5 weeks, p = 0.0061), deliveries < 37 gestational weeks (40 vs 69.2%, p = 0.0159), live births (93.3 vs 69.2%, p = 0.0143) and the duration of pregnancy prolongation in terms of live births (19.5 ± 5.0 vs 12.0 ± 8.2 weeks, p = 0.0002). There was a higher cesarean section rate in prophylactic group than that in therapeutic group (50 vs 25.6%, p = 0.0383). The logistic analysis showed that the cervical length before surgery was the only independent prognostic factor [OR 2.860 (1.425, 5.742) p = 0.0031] for pregnancy outcome, and that is the cervical length before surgery affected late foetal loss.

CONCLUSIONS

Our study suggests that, both prophylactic cervical cerclage and therapeutic cervical cerclage reduce the incidence of recurrent abortion or preterm birth and efficiently extend the length of the pregnancy with live births. The prophylactic cervical cerclage has more advantages in operative time, length of hospital stay after surgery, gestational age at delivery, live births and preterm birth. The length of the cervical before surgery is an independent risk factor for pregnancy outcomes when pregnant women appear in the cervical shortening is less than normal. Cervical cerclage is an effective surgical technique to prevent recurrent abortion or late foetal loss.

Clinical guidelines for prevention and management of preterm birth: a systematic review

BACKGROUND

Clinical practice guidelines (CPG) endorse multiple strategies to prevent or manage preterm birth (PTB).

OBJECTIVES

To summarise CPG recommendations for PTB and identify areas of international consensus.

SEARCH STRATEGY

In May 2017 we searched for all CPG relevant to PTB without language restrictions.

SELECTION CRITERIA

CPG were eligible if the following criteria were met: (1) the guideline was published or current from June 2013; (2) the guideline recommended practices for the prevention or management of PTB relevant to our prespecified clinical questions for screening, medications or surgery and other interventions; (3) publications on methods of guideline development for eligible CPG were included to enable quality assessment.

DATA COLLECTION AND ANALYSIS

Two authors classified CPG recommendations relevant to prespecified clinical questions. When more than 70% of CPGs reporting on a topic recommended or rejected an intervention, we regarded this as consensus. We summarised recommendations in tables.

MAIN RESULTS

We identified 49 guidelines from 16 guideline developers. We found consensus for several clinical practices: cervical length screening for high-risk women; short-term tocolysis; steroids for fetal lung maturation; and magnesium sulphate for fetal neuroprotection. We found discrepant recommendations for progesterone and fibronectin. No guideline identified an effective strategy for women with multiple pregnancy.

CONCLUSIONS

We identified interventions for which there is an international consensus on benefit for PTB. Systematic reviews of CPG using standardised methodology will help avoid duplication and target scarce resources for guideline developers globally.

TWEETABLE ABSTRACT

International clinical guidelines agree on the benefits and harmful effects of several important interventions to prevent preterm birth.

Successful Rescue Cerclage in a Monochorionic Diamniotic Twin Pregnancy at 20 Weeks: Case Report and Overview of Literature

BACKGROUND

In twin pregnancies, elective cerclage placement based on obstetrical history or ultrasound findings has been shown to be ineffective and even harmful. There are currently no guidelines for the use of rescue cervical cerclage in twin pregnancies.

CASE

The current report presents the case of a 33-year-old patient with monochorionic diamniotic twins (MCDA) found to have dilated cervix at 3.5cm with exposed membranes upon physical examination at 19 weeks and 3 days. An emergency McDonald cerclage was placed at 20 weeks and the patient carried the current pregnancy until 35weeks 6 days.

CONCLUSION

Rescue cerclage represents an important option to consider in order to preserve twin pregnancies regardless of chorionicity.

History-indicated cerclage: the association between previous preterm history and cerclage outcome

OBJECTIVE

Our hospital's policy is to perform history-indicated cerclage (HIC) for pregnant patients with 1 or more second-trimester pregnancy losses. Recently, the American College of Obstetricians and Gynecologists (ACOG) guideline regarding indications for HIC was changed from 3 or more previous second-trimester fetal losses to one or more. In this study, we aimed to evaluate the efficacy of the revised guideline and to investigate the association between previous preterm history and cerclage outcome.

METHODS

We conducted a retrospective observational study of cases of HIC in singleton pregnancies performed at our hospital between January 2007 and June 2016. We compared the perioperative complications and incidences of preterm delivery in patients with one previous second-trimester pregnancy loss against those in patients with ≥2 losses.

RESULTS

The incidence of preterm delivery (<32 weeks) was significantly lower in patients with one previous second-trimester pregnancy loss than in those with ≥2 losses (15/194 [8%] vs. 28/205 [14%]). In the 1 loss and ≥2 losses groups, the rates of preterm premature rupture of membranes (PPROM) were 7% and 8%, the rates of PPROM at <32 weeks 2.1% and 3.4%, and the ratios of neonatal intensive care unit admission 10% and 17%, respectively.

CONCLUSION

Comparison of HIC in one previous second-trimester pregnancy loss group with HIC in the 2 or more previous second-trimester pregnancy loss group found no difference in pregnancy outcome. This finding supports the amended ACOG guideline for HIC indications. Based on our results, we also propose development of a new protocol for HIC-related complications.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cervical cerclage placement decreases local levels of proinflammatory cytokines in patients with cervical insufficiency

BACKGROUND

Cervical insufficiency is characterized by premature, progressive dilation and shortening of the cervix during pregnancy. If left unattended, this can lead to the prolapse and rupture of the amniotic membrane, which usually results in midtrimester pregnancy loss or preterm birth. Previous studies have shown that proinflammatory cytokines such as interleukin-1β, interleukin-6, interleukin-8, and tumor necrosis factor alpha are up-regulated in normal parturition but are also associated with preterm birth. Studies evaluating such markers in patients with cervical insufficiency have evaluated only their diagnostic potential. Even fewer studies have studied them within the context of cerclage surgery.

OBJECTIVES(S)

The objective of the study was to evaluate the impact of local and systemic inflammatory markers on the pathogenesis of cervical insufficiency and the effect of cerclage surgery on the local immune microenvironment of women with cervical insufficiency.

STUDY DESIGN

We recruited 28 pregnant women (12-20 weeks' gestation) diagnosed with insufficiency and referred for cerclage surgery and 19 gestational age-matched normal pregnant women as controls. Serum and cervicovaginal fluid samples were collected before and after cerclage surgery and during a routine checkup for normal women and analyzed using a targeted 13-plex proinflammatory cytokine assay.

RESULTS

Before surgery, patients with cervical insufficiency had higher levels of interleukin-1β, interleukin-6, interleukin-12, monocyte chemoattractant protein-1 and tumor necrosis factor alpha in cervicovaginal fluid compared to controls, but after surgery, these differences disappeared. No differences were found in serum of insufficiency versus control women. In patients with insufficiency, the levels of interleukin-1β, interleukin-6, interleukin-8, monocyte chemoattractant protein-1, and interferon gamma in cervicovaginal fluid declined significantly after cerclage compared with before intervention, but these changes were not detected in serum.

CONCLUSION

Compared with normal women, patients with cervical insufficiency have elevated levels of proinflammatory cytokines in cervicovaginal fluid but not in serum, suggesting a dysregulation of the local immune environment. Cerclage intervention led to a significant decline in these proinflammatory cytokines, suggesting that cerclage may help reduce local inflammation in cervical insufficiency.